COMPLICATIONS—HYPOGLYCEMIA

COMPLICATIONS—HYPOGLYCEMIA & 390-P The Novel Glucagon Analogue ZP-GA-1 has Superior Physico- Guided Audio Tour: Predictors, Morbidity, and Mortality (Posters: 389-P to chemical Properties while Maintaining the Pharmacokinetic and 395-P), see page 17. Pharmacodynamic Profi le of Native Glucagon & 389-P DITTE RIBER, ANDERS VALEUR, METTE SVENDGAARD, FRANCESCA MACCHI, Benefi t-Risk Relationship between A1C and Hypoglycemia for LISE GIEHM, KELD FOSGERAU, PIA NOERREGAARD, Copenhagen, Denmark Glucagon is used in diabetic patients for treatment of severe episodes of

Addition of Exenatide BID to Insulin Glargine in Patients with T2DM POSTERS

JARET MALLOY, MING ZHOU, JENNY HAN, San Diego, CA, Hopewell, NJ hypoglycemia. Pharmaceutically, however, native glucagon possesses poor Complications Exenatide BID (ExBID) improves postprandial glucose and A1C with low physicochemical properties, making convenient dosing in a ready-to-use Acute and Chronic hypoglycemia (hypo) risk. Two 30-wk studies evaluated insulin glargine (IG; rescue pen or the development of an artifi cial pancreas diffi cult. Accordingly titrated per algorithm based on fasting glucose [goal <100 mg/dL]) + ExBID. In the development of novel glucagon analogues such as ZP-GA-1 is pursued. Study 1 (N=627), ExBID or insulin lispro (IL) was added to IG + metformin. In Study The solubility of ZP-GA-1 at physiological pH was shown to be >25 mg/mL 2 (N=259), ExBID or placebo was added to IG ± metformin and/or pioglitazone. and thus highly superior to that of native glucagon ~0.2 mg/mL. In addition, IL was titrated based on pre-meal glucose (goal =100 mg/dL with no hypo). We the stability data suggests that ZP-GA-1 is suitable for long term storage as quantifi ed the benefi t-risk relationship between A1C lowering and hypo risk a liquid formulation. The pharmacokinetic (PK) and pharmacodynamic (PD) versus comparators using Poisson regression models to evaluate hypo exposure- properties of ZP-GA-1 and native human glucagon were investigated in dogs. adjusted event rates (EAER) adjusted for the lowest A1C observed over 30 wks. In Animals were administered either subcutaneously (SC, 20 and 120 nmol/ both studies, IG + ExBID signifi cantly reduced A1C and weight. Study 1: With the kg) or intravenously (IV, 75 nmol/kg). Our data demonstrated overall similar same A1C achieved, hypo EAER was 58% less with IG + ExBID vs. IG + IL (risk ratio PK profi les as well as blood glucose (BG) profi les of ZP-GA-1 and glucagon. [RR] 0.42; p<.0001; Figure 1A). IG + ExBID reduced daytime (RR 0.19; p<.0001) and Further, the SC effect of ZP-GA-1 on BG in a rat model of hypoglycemia nocturnal hypo EAER (0.86; p=.076) vs. IG + IL. Overall, being female, lower BMI was investigated (Figure). Both ZP-GA-1 and glucagon restored BG to or longer diabetes duration resulted in signifi cantly higher hypo EAER. Study 2: baseline levels or above in a dose-dependent manner during insulin-induced hypo EAER was slightly lower for IG + ExBID than IG + placebo (RR=0.75; p=.107; hypoglycemia. In conclusion, ZP-GA-1 displays improved physicochemical Figure 1B). IG + ExBID signifi cantly reduced A1C and weight, and the modeled properties while maintaining similar PK and PD profi les compared to native A1C and hypo ben efi t-risk relationship further supported use of ExBID with IG glucagon. for patients with T2DM not at goal with titrated IG.

& 391-P Naltrexone for Treatment of Hypoglycemia Unawareness in Type 1 Diabetes: A Randomized Clinical Trial AMIR MOHEET, SILVIA MANGIA, ANJALI KUMAR, NOLA TESFAYE, LYNN E. EBERLY, YUN BAI, ELIZABETH R. SEAQUIST, Minneapolis, MN Hypoglycemia unawareness (HU) is a limiting factor in the treatment of type 1 diabetes (T1D) and is a challenging problem to reverse. Previous studies have suggested that the opioid receptor antagonist naltrexone might be of benefi t in treatment of HU. The objective of this study was to test the hypothesis that naltrexone therapy in subjects with T1D and HU will improve counterregulatory (CR) hormone response, recognition of hypoglycemia (HG) symptoms and increase brain activation during HG in regions involved in the regulation of CR response to HG as measured by cerebral blood fl ow (CBF) using fMRI. We performed a pilot randomized double blind trial of 4 weeks of naltrexone 50 mg bid (n=11) or placebo (n=12) given orally in subjects with T1D and HU. Outcome measures included HG symptom scores, CR hormone levels and CBF measurement obtained during experimental HG in all subjects before and after 4 weeks of intervention. Subjects were defi ned as having HU based on Cox questionnaire. Baseline subject characteristics were similar between the naltrexone (A1C 7.0 ±0.6, Cox score 5.3±0.9) and placebo (A1C 6.5±0.7, Cox score 5.8±0.9) arms. After 4 weeks of therapy with naltrexone or placebo, no signifi cant differences were seen in any outcomes of interest within each group or between the treatment and placebo arms. At the end of study HG symptom scores (10±7 vs. 14±12, P=0.47) and CR hormone response including epinephrine (116±154 vs. 97±99 pg/ml, P=0.75), glucagon (65±40 vs. 47±12 pg/ml, P=0.25) and cortisol (19±7 vs. 20±8 mg/dl, P=0.35) were similar between the 2 groups. No differences were also seen in the brain activation pattern in response to HG between the 2 groups. In this small pilot study, treatment with naltrexone did not improve recognition of HG symptoms or CR hormone response during experimental HG in subjects with T1D and HU. Future studies with larger sample sizes and different dosing regimens will be necessary to fully evaluate the effi cacy of naltrexone as a treatment of HU. Supported By: ADA (7-07-DCS-02)

Supported By: Bristol-Myers Squibb/AstraZeneca

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A103 COMPLICATIONS—HYPOGLYCEMIA

& 392-P & 394-P Recent vs. Remote History of Severe Hypoglycemia (SH) as a Predictors of Hypoglycemia in Insulin-Treated Type 1 (T1) and Type Predictor of Mortality in Type 1 Diabetes (T1D) 2 (T2) Diabetes Patients: Analysis of Self-Reported Hypoglycemic GEORGIA PAMBIANCO, TINA COSTACOU, TREVOR J. ORCHARD, Pittsburgh, PA Events in 10 European Countries A history of SH has been associated with increased mortality in type 2 DOMINGO OROZCO-BELTRAN, PEDRO MEZQUITA-RAYA, WERNER KERN, BERN- diabetes. While in T1D up to 10% of deaths can be attributable to acute HARD KULZER, JORMA LAHTELA, ULRIK PEDERSEN-BJERGAARD, RAIMUND hypoglycemia, the role of a history of SH is unclear. We thus examined WEITGASSER, PETRONELLA GEELHOED-DUIJVESTIJN, CHANTAL MATHIEU, POSTERS

Complications data from the ongoing Epidemiology of Diabetes Complications study of HENRIK HOLM JENSEN, ANTONIO RAMIREZ DE ARELLANO, MARIE MARKERT

Acute and Chronic childhood onset T1D (mean age 28 and duration 19 years, n=658 at baseline JENSEN, San Juan de Alicante, Spain, Almería, Spain, Ulm, Germany, Bad (1986-88)) to determine if a self reported history of SH in the prior 2 years, Mergentheim, Germany, Tampere, Finland, Hillerød, Denmark, Salzburg, Austria, The is associated with total (n=76), CAD (no renal, n=27), renal (no CAD, n=14) or Hague, Netherlands, Leuven, Belgium, Holte, Denmark, Madrid, Spain, Copenhagen, CAD+renal (n=19) mortality, in 443 participants attending the 1990-92 exam Denmark when these questions were fi rst asked. SH was defi ned as unconsciousness, Unpredictability of hypoglycemia is an ever-present threat of insulin requiring assistance and/or having a low blood sugar (<50 mg/dl) without therapy and measures to prevent its incidence depend on knowledge of recognition. Death was classifi ed according to Diabetes Epidemiology predictors. The identifi cation of clinical and socio-demographic factors as Research International (DERI protocol) by a physician committee. Baseline markers of hypoglycaemia may improve diabetes management. (1990-1992) and most recent history of SH analyses were performed. The “Hypoglycemia in Insulin Treated diabetes” (HIT) Study included 5483 Separate multivariable Cox models were determined for each outcome based T1 and insulin-treated T2 patients in 10 European countries who reported on univariate signifi cance of previously established predictors. Baseline or rates of non severe hypoglycaemic events (NSHE) and related matters via 4 recent history of SH was forced into each model. The median time from online questionnaires. last follow up to death was 1.5 years. SH 2 years before baseline was not Risk markers were identifi ed in regression models. Weighting ensured independently related to total, CAD, renal, or CAD+renal mortality. SH in sample size and demographic features were similar in the 10 countries. the prior 2 years at most recent exam was not related to CAD or CAD+renal Markers of high frequency of NSHE for T1 patients were: female gender, mortality but was independently related to total mortality (HR=1.79, 1.1-2.9); longer duration of insulin treatment, >1 daily injections, Body Mass Index other predictors were diabetes duration, estimated glomerular fi ltration rate and perceived poor advice on hypoglycemia from GP (Table). Markers for T2 (eGFR), HbA1c, hypertension, smoking, albumin excretion rate (AER), and patients were the same, except for BMI. No statistical signifi cant association nonHDLc. A univariate association with renal mortality (HR=3.84, 1.3-10.9 was found with living status, primary education and work for pay. was weakened (HR=2.57, .89-7.4, p=0.08) with the addition of eGFR and AER. Gender, insulin duration and daily injections were found to be strong We conclude that SH in the last 1-4 years doesn’t increase CAD mortality predictors of NSHE in T1 and T2 diabetes. In T1 increasing BMI reduced risk but may increase total and renal mortality, though that latter is partially the NSHE risk. The multifactorial nature of hypoglycaemic phenotype was explained by diminished renal function. confi rmed and an important contribution from insulin regimen and a role of Supported By: DK0234818 the health professionals were identifi ed.

& 393-P Univariate Linear Regression Models Results. Baseline Insulin Defi ciency Is Associated with Increased Mortality Type 1 diabetes Type 2 diabetes and Severe Hypoglycemia in the ACCORD Study mellitus mellitus (n=2185) (n=2467) ELIZABETH R. SEAQUIST, HAIYING CHEN, MICHAEL E. MILLER, SANTICA M. MARCOVINA, LISA CHOW, Minneapolis, MN, Winston-Salem, NC, Seattle, WA Parameter Beta* P-value Beta* P-value Intensive glycemic control is associated with increased mortality, but Body Mass Index (BMI) -2.68 <0.0001 -0.26 0.1283 the role of hypoglycemia remains unclear. Hypoglycemia is associated with Female Gender (yes = 1) 27.30 <0.0001 11.43 <0.0001 insulin defi ciency. Whether insulin defi ciency and/or islet autoimmunity may Duration on Insulin Treatment 0.67 0.0002 0.75 <0.0001 affect mortality in patients with type 2 diabetes (T2DM) remains unknown. Using the ACCORD cohort, we tested the hypothesis that baseline insulin Number of Daily Insulin Injections 13.02 <0.0001 5.52 <0.0001 defi ciency and islet autoimmunity in T2DM would be associated with severe General Practitioner Gives Good -15.79 0.0016 -6.52 0.0075 hypoglycemia (SH) and mortality. Advice About Hypos (yes = 1) A nested case-control study (86 cases, 344 controls) was used. A Table legend: (*) Magnitude of the contribution of each explanatory variable on the participant who died during ACCORD with at least 1 episode of SH, defi ned frequency of hypoglycemic events. as hypoglycemia requiring assistance, was classifi ed as a case. Participants Supported By: Novo Nordisk A/S who did not die during ACCORD and did not have SH were classifi ed as controls. Each case was matched to 4 controls [age (+/- 5 yrs), BMI (+/- 2.5), glycemic intervention arm, race]. Insulin defi ciency was defi ned as fasting & 395-P C-peptide < 0.45 nmol/L. Islet autoimmunity was determined by antibodies An Archimedes Model of Mild Hypoglycemia against glutamic acid decarboxylase (GAD), tyrosine phosphatase-related STUART SAMUEL, KRISTINA S. BOYE, BADRI RENGARAJAN, BRADLEY H. islet antigen 2 (IA-2A), insulin (IAA), and zinc transporter (Zn-T8). Conditional CURTIS, SARAH CURTIS, San Francisco, CA, Indianapolis, IN logistic regression was used. While the consequences of mild hypoglycemia may be considered Death during ACCORD with at least 1 episode of SH was associated insignifi cant, many patients experience limitation to daily functioning, with baseline insulin defi ciency (OR 4.8, 95% CI 2.1-11.1, p<0.01) and GAD while the high rate at which these events occur may infl uence patient and antibodies (OR 2.3, 95% CI 1.1-5.1, p=0.04). These associations remained prescriber willingness to continue or intensify therapy. after adjusting for age and BMI (insulin defi ciency: OR 6.5, 95% CI 2.6-16.4, We used data from publically available sources (14 for Type 1 diabetes p<0.01; GAD antibodies: OR 2.4, 95% CI 1.0-5.4, p=0.04). Other baseline [T1DM] and 33 for Type 2 diabetes [T2DM]) to construct a model of mild antibodies (IA2, IAA, Zn-T8) had no association. GAD antibodies were hypoglycemia. For patients with T1DM, the rate (events/patient/year) depends more common in insulin defi cient (54.6%) than non-insulin defi cient (4.9%) HbAc1 - 7% only on the current value of HbA1c: RType1 = 109 x 0.8 . For T2DM, it participants. depends on BMI, duration of diagnosed diabetes, HbA1c, nephropathy (GFR), In patients with T2DM, insulin defi ciency, possibly due to islet cell BMI - 33 and the medications used: RType2 = baseRate (medications)/1.2 x 0.95 x autoimmunity, is associated with death and a history of SH. Whether 1.037diabetesDuration - 9 yrs x 0.82HbAc1 - 7% x (Maximum of 1 and Exp (10.0(GFR-0.86655 treatments to preserve insulin secretion in T2DM may reduce mortality _ 60-0.86655)), where the base rate for basal-insulin therapy is 8.5 ± 2.7 for the remains an intriguing area for further study. standard care arms of trials and 6.25 ± 3 for general practice and is reduced by factors of 0.55, 0.8 and 0.5 when used with respectively metformin, a sulfonylurea and both. The base rate for a sulfonylurea is 3 ± 1.4 for general care and is reduced by 0.85 when used with metformin. The model was independently validated against 14 results from 10 studies for T2DM (y=x line in Figure represents perfect prediction) and works reasonably well except for four “outliers” from two studies. Understanding

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A104 COMPLICATIONS—HYPOGLYCEMIA the rate of mild hypoglycemia is important and should be included in caregivers. In our previous work, we trained models utilizing patient SMBG modeling the outcomes associated with diabetes. values alone. In the current study, we investigated whether a model which took into account patient medications would have improved sensitivity and specifi city. We used de-identifi ed self-monitored blood glucose (SMBG) data and medication information from a randomized controlled trial (Quinn et al., 2011) to train a probabilistic model. For each data sample, 11 SMBG data points were used in the 7 days prior to a hypoglycemic event (defi ned as SMBG <70 POSTERS

mg/dL). Control samples used for training contained no hypoglycemia on the Complications

8th day. The model was constructed to predict the hour of the occurrence of Acute and Chronic hypoglycemia. In order to validate the model after training, 2,099 samples not used for training the model were presented to the model without the SMBG data from the 8th day. Sensitivity and specifi city for predicting the hour of hypoglycemia or no hypoglycemia on day 8 were then calculated. Further validation was performed with another distinct data set of 524 samples. The trained model correctly predicted the hour of hypoglycemia for 938 occurrences in the fi rst data set and 227 occurrences in the second data set. The mean sensitivity and specifi city of the predictions were 89.0% and 92.1%, respectively. In conclusion, this novel hypoglycemia prediction model, which utilizes both SMBG data as well as medication information, can predict hypoglycemia with a high degree of sensitivity and specifi city. Unlike other methods which require continuous glucose monitoring, this model uses sparse data (1.6 SMBG/day), which is similar in frequency to how patients with type 2 diabetes self-monitor. Given that the model is constructed to predict the hour of hypoglycemia, it may be very useful in a real-time mobile health application. Guided Audio Tour: Hypoglycemia—Drugs Causing and Drugs Reversing (Posters: 396-P to 403-P), see page 17. & 398-P Continuous Glucose Monitoring in 432 T2D Patients for Assessment & 396-P of Safety and Cost effectiveness in Reaching A1C Targets Severe Hypoglycaemia and All-Cause Mortality in Swedish Type 1 JOTHYDEV KESAVADEV, ARUN SHANKAR, JAYASREE LALLY, GEETHU SANAL, Diabetes Patients GOPIKAKRISHNAN GOPALAKRISHNAN, SUNITHA JOTHYDEV, Trivandrum, India TOM LUNG, PHILIP M. CLARKE, DENNIS PETRIE, ANN-MARIE SVENSSON, Benefi ts of intensive glycemic control in preventing vascular complications ANDREW J. PALMER, WILLIAM H. HERMAN, BJORN ELIASSON, Melbourne, of diabetes & as a cost effective modality is largely offset by episodes/ Australia, Gothenburg, Sweden, Tasmania, Australia, Ann Arbor, MI fear of hypoglycemia with fatal consequences.Despite limitations & higher Patients with Type 1 diabetes are susceptible to hypoglycaemic events costs,CGM detects glucose trends not revealed by SMBG. We analysed data due to the nature of the disease requiring insulin replacement therapy. of 432 T2D (male 243, female 189), aged 52.2 (15.04) on professional CGM The aim of this study was to examine whether severe prior hypoglycaemic over 6-7 days in past 1 year. Nocturnal hypoglycemia (31.86%) hypoglycemia events were associated with the risk of all-cause mortality in patients with unawareness (19.32%) & Somogyi (2.50%) were observed. Therapeutic & Type 1 diabetes. lifestyle modifi cations were carried out (Table 1) & A1c reassessed (Table 2). This study is based on a large linked dataset comprising of health records Cost effectiveness was analysed as incremental Cost/QALY gained. from the Swedish National Diabetes Register (NDR). We selected patients CGM was projected to reduce lifetime probability of hypoglycemic with Type 1 diabetes who visited a clinic between the 1st January 2002 episodes & may be recommended as routine in T2D to achieve safe A1c and 31st December 2010. Data from the NDR were confi dentially linked targets with confi dence. to patient level hospital records of inpatient episodes from the National Inpatients Register and death records (until 31st December 2012). A severe Modifi cations After CGM. hypoglycaemic event and other hospitalised events were identifi ed through Modifi cations % of patients Swedish hospitalisation codes. Diet and exercise 88.50 We derived a Cox proportional hazards model which takes into account OHA 30.00 clinical risk factors and previous disease history collected by the NDR that may affect all-cause mortality. Shift to different regimen 10.50 There were 27,964 type 1 diabetes patients of which 1,994 had previously Change in time of insulin 13.50 experienced a severe hypoglycaemic event and 2,254 died within our study Change in dose of insulin 41.21 period. A prior hypoglycaemic event was associated with a signifi cant increase in Change in insulin 7.00 all-cause mortality, with hazard ratios estimated to be 1.47 (95% CI 1.31-1.66). While there is some evidence from the Action in Diabetes and Vascular Recommended CSII 21.00 Disease (ADVANCE) trial on the impact of severe hypoglycaemia on all-cause mortality in Type 2 diabetes, there is limited evidence in Type 1 patients. The The Difference in Means of HbA1c at 0 and 3 Months. NDR provides scope to analyse this issue given its large sample size, follow- Regimen Percentage of patients Mean HbA1c ± SD Mean HbA1c ± SD up and linked hospital data. on various regimens (at 0 months) (at 3 months) We have found evidence that Type 1 diabetes patients with severe prior Basal 10.63 7.89 ± 1.218 6.97 ± 1.419 hypoglycaemic events have an increased risk of all-cause mortality in Sweden. This study highlights the potential importance of preventing severe Basal Bolus 21.35 8.64 ± 1.354 7.35 ± 1.379 hypoglycaemic events in Type 1 diabetes patients. Basal Plus 2.08 8.41 ± 0.910 7.01 ± 0.866 & 397-P Biphasic 21.88 9.46 ± 1.238 7.21 ± 1.485 Hypoglycemia Prediction Using SMBG Data and Patient Medication Insulin Pump 39.06 8.41 ± 1.446 7.10 ± 1.526 Information BHARATH SUDHARSAN, MANSUR E. SHOMALI, Baltimore, MD OHA 5 6.89 ± 1.667 6.07 ± 1.611 Hypoglycemia is a major adverse event in patients with type 2 diabetes. We have been working on methods which could predict when hypoglycemia would occur in order to use mobile health technology to warn patients or

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A105 COMPLICATIONS—HYPOGLYCEMIA

including increased production of advanced glycation end products (AGEs), & 399-P increased expression of receptor for AGEs or polyol pathway fl ux. The The Risk of Hypoglycemia among Sulfonylureas Is Lowest with effect of hypoglycemia on pathways activated by hyperglycemia is much Gliclazide: A Network Meta-analysis of Randomized, Controlled less explored. Therefore we aimed to test the effect of low glucose on the Trials expression of proteins/enzymes with established role in the hyperglycemia- STIG E. ANDERSEN, MIKKEL B. CHRISTENSEN, Roskilde, Denmark, Copenhagen, driven cell damage in vitro. Specifi cally, we evaluated mRNA expression Denmark of superoxide dismutase (SOD1), heme oxygenase (HMOX), p65 subunit of Sulphonylureas (SUs) are widely used as an inexpensive, second-line nuclear factor kappa B, glyoxalase 1 (GLO1), receptor for advanced glycation POSTERS

Complications treatment for type 2 diabetes. Hypoglycemia is the most important adverse end products and DJ-1 (an enzyme with established glyoxalase activity).

Acute and Chronic effect of SUs and the risk may vary among the various SUs, but direct Primary human umbilical vein endothelial cells were grown in EBM2 evidence from head-to-head comparisons is sparse. medium for 48 hours and then cultured for 24 hours in medium with different We compared the risk of hypoglycemia with newer generation SUs in content of glucose: (i) normoglycemic (5.5 mmol/l), (ii) hyperglycemic (25.5 patients with type 2 diabetes in a Bayesian network meta-analysis. We mmol/l) and (iii) hypoglycemic (2.75 mmol/l). Total RNA was extracted and included randomized actively and placebo controlled trials (RCTs) with reverse transcribed using commercial kits (Roche). Gene expression was duration of 12-52 weeks evaluating the effect of an SU added to on- determined using predesigned TaqMan probes (Life Technologies). Results going inadequate metformin monotherapy (1000 mg/day) in adult patients were normalized to 18-S RNA. with type 2 diabetes. To establish a coherent network (allowing for mRNA expression of all studied genes was increased in response to indirect comparisons), we included additional RCTs in similar population hyperglycemia compared to normoglycemia as expected although statistical investigating one of the active comparators in the primarily included SU signifi cance was reached only in case of SOD1 and p65 (P < 0.05). Similar trials. The primary endpoint was frequency of any hypoglycemia. Data trends were observed in low glucose conditions compared to normoglycemia on severe hypoglyemia, reduction in hemoglobin A1C (HbA1C), and weight with exception of HMOX expression which was slightly but not signifi cantly change were also extracted. lower (P > 0.05). We included 11 trials of SUs and 13 trials of other oral antihyperglycemic Our results suggest that hypoglycemia may have similar effect on primary agents, lasting 16 to 52 weeks and including 14,022 patients. Overall, 9.5% endothelial cells with respect to established damaging pathways. had experienced hypoglycaemia, including 21.5% of the patients enrolled Supported By: Czech Republic Ministry of Health (NT13198) for SU. The risk of hypoglycemia was signifi cantly lower with gliclazide than with glibenclamide (odd ratio (OR): 0.14, 95% credibility interval (CrI): & 402-P 0.02 to 0.80) and glipizide (OR 0.15, CrI: 0.03 to 0.58). The risk associated Rate Ratios for Nocturnal Confi rmed Hypoglycemia with Insulin with glimepiride was not signifi cantly different from risk of the other SUs, Degludec vs. Insulin Glargine Using Different Defi nitions but borderline inferior to gliclazide (OR: 0.44, CrI: 0.13 to 1.26. Severe SIMON R. HELLER, CHANTAL MATHIEU, RAHUL KAPUR, MICHAEL L. WOLDEN, hypoglycemia was not reported for glibenclamide or gliclazide, but for 0 to BERNARD ZINMAN, Sheffi eld, United Kingdom, Leuven, Belgium, Søborg, Denmark, 1.4% and 0 to 2.6%, respectively, of the patients treated with glimeperide Toronto, ON, Canada or glipizide. The SUs had comparable effect on HbA1C and body weight. A previously published prospectively planned meta-analysis of 26- or We conclude that when added to metformin, gliclazide confers the lowest 52-week randomized treat-to-target trials examined rates of nocturnal risk of hypoglycemia among the SUs, while being similar in terms of HbA1C confi rmed hypoglycemia (self-reported confi rmed events with PG <56 mg/ control and risk of weight gain. dL or severe events requiring assistance, occurring from 0:01-5:59 incl.) with insulin degludec (IDeg) and insulin glargine (IGlar). Analyses utilized & 400-P a negative binomial regression model on patient-level data. Rates were Glycation Gap: Potential Contribution from Physiological Anions signifi cantly lower with IDeg in insulin-naïve T2DM (3 trials) and basal-bolus SHELLEY L.D. CLARK, BARBARA GARAY-NONTAL, MARGARET MURDOCK, R.W. (BB)-treated T2DM (1 trial), and numerically lower in T1DM (2 trials). We now HOLMAN, KENNETH J. RODNICK, Pocatello, ID report on multiple sensitivity analyses performed including: 1) only confi rmed Glycation gap (G-gap) was developed to assess the difference between episodes with symptoms, 2) the ADA defi nition (symptoms + PG <70 mg/dL), measured HbA1c levels and HbA1c predicted from fructosamine values. A and 3) a different time frame for the ‘nocturnal’ period. Results were robust, positive G-gap is clinically important because it has been associated with confi rming signifi cantly or numerically lower rates with IDeg vs. IGlar for the diabetic retinopathy, nephropathy, macrovascular disease and mortality. period 0:01-5:59 (table). Rates also were lower with IDeg when ‘nocturnal’ HbA1c levels are determined by intracellular (erythrocyte) glycation events was extended to 8 hours from 21:59-5:59. whereas fructosamine refl ects extracellular glycation of serum proteins. As a The robustness of the fi ndings showing a reduced rate ratio of nocturnal result, fundamental differences in the chemical composition of physiological confi rmed hypoglycemia with IDeg vs. IGlar in T2DM utilizing different compartments may contribute to the G-gap. A combined computational and defi nitions suggests that similar fi ndings will be seen in clinical practice. NMR study was undertaken to assess the potential role of physiological anions [inorganic phosphate (Pi), bicarbonate (HCO3-), and lactate] on the Rate ratio for nocturnal confi rmed hypoglycemia, early-binding events of the glycation process involving human hemoglobin IDeg/IGlar Estimate [95% confi dence intervals] (HbA) and serum albumin (HSA). Both HbA and HSA are known to undergo Pi and HCO3- - facilitated glycation in vitro, and both proteins must bind ring- T2DM T2DM T1DM closed glucose isomers that ring open while bound. We now demonstrate insulin-naïve basal-bolus IDeg N=637 that glucose isomers have a greater binding affi nity for HSA than for HbA. IDeg N=1279 IDeg N=742 IGlar N=316 IGlar N=631 IGlar N=248 In HbA, physiological anions and glucose isomers can simultaneously bind Nocturnal confi rmed hypo. 0.64 [0.48, 0.86]* 0.75 [0.58, 0.99]* 0.83 [0.69, 1.00] within common pockets known to glycate (e.g. Val1/Lys82, Lys59, Lys17) with a comparable exothermicity relative to binding of the sugar alone. Moreover, (original defi nition) (0:01-5:59) in aqueous solution the rate of glucose ring-opening (mutarotation) by Nocturnal confi rmed symp. hypo.b 0.56 [0.39, 0.80]* 0.68 [0.51, 0.91]* 0.88 [0.72, 1.08] anion facilitation as measured by NMR is in the order of Pi, bicarbonate, (0:01-5:59) and lactate. As such, co-binding of one or more physiological anions with Nocturnal ADA documented symp. hypo.c 0.73 [0.56, 0.97]* 0.72 [0.55, 0.93]* 0.91 [0.74, 1.11] a ring-closed glucose isomer likely facilitates ring opening and enhances (0:01-5:59) progression towards glycated protein. Thus, in addition to differences in the Nocturnal confi rmed hypo. 0.60 [0.45, 0.80]* 0.73 [0.59, 0.91]* 0.88 [0.76, 1.03] glucose gradient across the red cell membrane and protein life span, differing (21:59-5:59)d concentrations of physiological anions in the intracellular and extracellular a: PG <56 mg/dL or severe hypoglycemia requiring assistance; b: Confi rmed hypo with symp- environments may play a role in defi ning the G-gap. toms; c: ADA defi nition (symptoms + PG <70 mg/dL); d: Original defi nition with time of ‘noctur- nal’ varied; hypo, hypoglycaemia; symp, symptomatic; *p<0.05. In some trials patients were & 401-P randomized to IDeg:IGlar in a ratio of 2:1 or 3:1. Hypoglycemia Increases Expression of Several Genes Upregulated Supported By: Novo Nordisk A/S by Hyperglycemia KATARINA KURICOVA, LUKAS PACAL, KATERINA KANKOVA, Brno, Czech Republic Hyperglycemia-induced overproduction of mitochondrial reactive oxygen species (ROS) is the key event in the development and progression of diabetic microvascular complications. ROS activates several harmful pathways

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A106 COMPLICATIONS—HYPOGLYCEMIA

licensing. We tested the hypothesis that the implementation of new stricter & 403-P EU legislation on driver’s licensing in Denmark in January 2012 reduces the Hypoglycemia in Bacterial Septicemia self-reported rate of severe hypoglycemia in a routine clinical setting. SUNAO MATSUBAYASHI, SHUICH MATSUMOTO, NOBUHIRO KODAMA, Kasuga, In a cohort study including 309 patients with type 1 diabetes numbers Japan of severe hypoglycemic events were retrieved from medical records and Objective: The aim of this study was to investigate whether hypoglycaemia furthermore indicated in an anonymous questionnaire administered under at admission correlates with the outcomes in Japanese septicemia. study conditions. Medical record data from 2010 and 2011 were compared Research Design and Methods: We collected data anonymously from with those from 2012 and with data from the questionnaire. POSTERS electronic medical records and analyzed them retrospectively. Initially, 818 Reported rates of severe hypoglycemia in the medical records were Complications positive blood culture sets were screened for participation in the study. reduced by more than 50% in 2012 compared to the prior years (p=0.034). Acute and Chronic Patients without diagnostic criteria of systemic infl ammatory response The fraction of subjects reporting multiple episodes was grossly reduced syndrome or clinically diagnosis as a contamination of blood culture were by 73% from 5.6% to 1.5% (p=0.014). Compared to the rate anonymously excluded. So, 311 patients were diagnosed with bacterial septicemia. 5 obtained in the questionnaire the rate of severe hypoglycemia in 2012 was patients were excluded because of missing blood glucose data. In the end, 70% lower (p<0.001). 306 patients were evaluated in this study. We conclude that reporting of severe hypoglycemia by patients with type Results: Hypoglycemia under 70 mg/dl was detected in 12 patients. 1 diabetes is signifi cantly hampered following implementation of EU driver’s Severe hypoglycemia under 40 mg/dl was observed in 6 patients. Of licensing legislation. This is primarily explained by a marked reduction in the hypoglycemic patients, 3 had diabetes mellitus. The prevalence of number of subjects reporting multiple episodes that according to the new hypoglycemia was 3.9 %. Mortality within 30 days and total of inhospital regulations implies withdrawal of driver’s licensing. mortality from all 306 patients was 13.3 % and 23.5 %, respectively. The prevalence of within 30 days mortality according to blood glucose levels at 406-P admission in patients with bacterial septicemia was 83.3, 66.3, 22.8, 7.8, Clinical and Genetic Analysis of 95 Cases of Congenital Hyper- 11.5, 12.9 percent for under 40 mg/dl, 41-70 mg/dl, 71-110 mg/dl, 111-170 mg/ insulinism dl, 171-200 mg/dl, over 201 mg/dl of blood glucose at admission, respectively. SHUYUE HUANG, CHUNXIU GONG, CHANG SU, Beijing, China The Kaplan-Meier curves demonstrated higher mortality in hypoglycemic To investigate the clinical outcomes and gene mutations related to patients than in those without hypoglycemia (log rank test P<0.001). congenital hyperinsulinism (CHI) in Chinese patients. We studied the Conclusion: The mortality of hypoglycemic Japanese patients with sepsis therapeutic outcomes of 95 cases of CHI and analyzed the associations patients within 30 days was signifi cantly higher than that of normoglycemic, between gene mutations and clinical features in 55 cases. Among all 95 or hyperglycemic patients with sepsis. CHI cases, 36 (38%) experienced misdiagnosis. 82 (86%) children were given diazoxide therapy based on an age-dependent feeding frequency, 404-P and 54 (66%) cases showed effective. Five patients were treated with GLP-1 Regulates the Metabolic Response during Acute Infl ammation octreotide for 1 to 4 months, and 4 showed a positive response. Non- and Predicts Unfavorable Outcome in Critically Ill Patients surgical therapy was effective in 71 (75%) cases. Four children received FLORIAN KAHLES, CHRISTINA MEYER, SEBASTIAN DIEBOLD, CORINNA LEBHERZ, subtotal pancreatectomy, and three had abnormal glucose metabolism. HANNES M. FINDEISEN, ALEXANDER KOCH, FRANK TACKE, NIKOLAUS MARX, The side-effects of diazoxide treatment included: sodium and water MICHAEL LEHRKE, Aachen, Germany retention in 55 (67%) cases, 4 cases showing intolerance; gastrointestinal Purpose: Hypoglycemia has been associated with increased mortality reactions in 41 (50%) cases, 8 intolerance and stopped; polytrichia in 25 in patients with sepsis or acute myocardial infarction. The underlying (30%) cases; and thrombocytopenia in 5 cases. One patient complicated mechanisms for infl ammation mediated hypoglycemia remain elusive. Since syndrome of inappropriate antidiuretic hormone. The remission rate of Glucagon-like-peptide 1 (GLP-1) causes insulin secretion, we hypothesized hypoglycemia was 59% and 71% for children over 2 and 3 years old, that GLP-1 may be of relevance for infl ammation induced hypoglycemia. respectively. Thirty-five (37%) patients had nervous complications. Methods and Results: GLP-1 serum levels were found to be 6,9 times The identified gene mutation rate was 38% for CHI-related genes higher in critically ill patients (n=155) in comparison to healthy controls and 33% for K channel-related genes, Early onset and lower diazoxide (n=134) (p<0.001) and independently predict unfavorable short- (p=0.001) respond rate were associated with gene mutations. we Conclude that and longer term (p=0.01) mortality. To evaluate potential mechanisms of Therapeutic outcomes based on age-dependent feeding were positive infl ammation dependent GLP-1 secretion we injected C57Bl6 mice with but varied greatly with subtotal pancreatectomy. The effectiveness of endotoxin. LPS caused an elevation of GLP-1 levels with a maximal 3,4 fold non-surgical therapy may partially be the result of a low K channel gene increase (p<0.001) after 120 minutes. This was paralleled by an increase mutation rate. Hence, we do not recommend operation before typing of serum insulin (p<0,001) and a drop of blood glucose (p<0.001). A similar can be clarified. increase of serum GLP-1 and insulin was observed after administration of -/- -/- IL1β or IL6. Experiments in IL1R and IL6 mice revealed that LPS dependent 407-P GLP-1 secretion was selectively dependent on IL6 but not on IL1 secretion. Emergency Medical Services First Response to Hypoglycemic Consistently IL6 (p<0.05) but not IL1 or LPS stimulated GLP-1 secretion β Events: The PAUEPAD Study from intestinal L cells in vitro. Interestingly, the antiinfl ammatory properties RAFAEL J. BARRANCO, FERNANDO GOMEZ-PERALTA, FRANCISCO ROMERO, of GLP-1 remain present during endotoxemia. To assess the functional MANUEL A. DE LA CAL, LUIS OLAVARRÍA, JOSE J. GARCIA, JOSE M. ALVAREZ, relevance of GLP-1 for glucose homeostasis in response to endotoxemia MANUEL GONZALEZ, FRANCISCO J. PASQUEL, GUILLERMO E. UMPIERREZ, we administrated the DPP4 inhibitor sitagliptin, which augmented LPS- Jaén, Spain, Segovia, Spain, Atlanta, GA induced insulin secretion (p<0,05) and blood glucose lowering (p<0,05) Hypoglycemia is a common and serious complication in patients with in C57Bl6 mice. Conversely, the GLP-1 receptor antagonist exendin 9-39 diabetes. The need for emergency medical service (EMS) care, outcome, blunted LPS-dependent increase of serum insulin and prevented endotoxic resource utilization, and cost of hypoglycemic emergencies are not known. hypoglycemia. The Public Company for Health Emergencies of Andalucía (EPES) provides Conclusion: We here found LPS dependent hypoglycemia to requiere an emergency medical services to a large population of ~8.5 million people in infl ammatory cascade including IL6, GLP-1 and insulin. Elevated GLP-1 serum Southern Spain. We present data on emergency services for hypoglycemia levels predict mortality in critically ill patients. between 01/2012 to 12/2012 in order to identify clinical characteristics, types of events, onsite treatment or need for emergency room or hospitalization, 405-P and mortality. Medical cost was estimated using adjusted €2012 unit prices Implementation of New EU Driver’s License Legislation May Hamper for public emergency services. During the study period, EPES received Reporting of Severe Hypoglycemia by Patients with Type 1 Diabetes 1,137,738 emergency calls requesting medical assistance; of them, 8,683 ULRIK PEDERSEN-BJERGAARD, LOUISE H. FÆRCH, BIRGER THORSTEINSSON, had a primary complaint of hypoglycemia (0.8%). A team of certifi ed EMS Hillerød, Denmark professionals under physician supervision screened all cases. A total of Health care professionals’ knowledge about occurrence of severe 975 cases (11.2%) resolved on site via telephone guidance. Dispatch of hypoglycemia in their patients with type 1 diabetes is crucial in order to an EMS team to provide domiciliary medical assistance was required in prevent future episodes. Patients may, however, choose to omit reporting 7,404 cases (85.3%). A total of 5,564 events (65%) involved patients >65 such episodes if they are at risk of restrictions e.g. in terms of driver’s years. Most cases were mild and resolved on site, and 1,784 patients (21%)

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A107 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

required transferring patients to the emergency room or hospital. The overall genes promoting lipid accumulation such as Adipocyte Lipid Binding Protein mortality was 0.32% (28 cases). The estimated cost for each hypoglycemic (ALBP). At the same time, TRB3 overexpression suppressed the infl ammatory event was €702, with an emergency service total cost of €6.093.507. posture of macrophages as evidenced by reduced expression of Tumor Hypoglycemic events requiring emergency room care accounted for 49% of Necrosis Factor alpha (TNF-a) and Monocyte Chemoattractant Protein-1 the total healthcare cost. (MCP-1) (both p<.01). In conclusion: 1) TRB3 is upregulated in macrophage Hypoglycemia is a common emergency associated with high rate of foam cells and promotes lipid accumulation associated with increased emergency medical service EMS utilization and health care cost. These expression of ALBP and suppression of ABCA-1. 2) TRB3 also suppresses results indicate the need of treatment protocols to improve outcome, cytokine expression and therefore orients the macrophage to assume a more POSTERS

Complications avoid hospitalizations, and reduce costs of patients with hypoglycemic primary role for lipid accumulation while maintaining a secondary role as an

Acute and Chronic emergencies. infl ammatory immune cell. Supported By: ADA (1-13-IN-19); U.S. Dept. of Veterans Affairs; University of 408-P Alabama, Birmingham; NIH Analysis of Hypoglycemic Events in Unemployed Patients SUSANA CAROLINA BERTOLA, JOSÉ MARIA POZZI, DANILA RE, JORGE WAIT- & 410-P MAN, Córdoba, Argentina Skin Microvascular Reactivity Relates to Advanced Glycation in Unemployed patients (UE) are particularly vulnerable to developing Patients with Type 1 Diabetes hypoglycemic events due to their inability to afford a treatment, especially JAN SOUPAL, JAN ŠKRHA, JR., JAN SKRHA, MARTIN PRAZNY, Prague, Czech as regards nutrition. A prospective longitudinal observational study was Republic conducted to characterize hypoglycemic events and their impact on UE The advanced glycation end products (AGEs) are involved in the patients measured against working ones. Follow-up: 1 year. Signifi cant pathogenesis of diabetic complications. Moreover, the development of p<0.05. Patients recruited: 393 diabetics within the framework of a Public diabetic microangiopathy is associated with changes of microvascular Hospital. Men: 57%. Age: 50±14 years. A1c: 8.6±2.6%. T2DM: 45%. IRT2DM: reactivity (MVR). The aim of the study was to compare MVR in Type 1 38%. T1DM: 17%. Low-literacy (primary school completed): 44.8%. UE: 46%. diabetic patients (T1D) with soluble receptor for AGEs (sRAGE) and the skin Among patients reporting hypoglycemic events only 39.9% had a permanent autofl uorescence (AF) refl ecting the accumulation of AGEs. job measured against 51.5% who were reportedly event-free (p<0.04. OR 1.7 Both skin AF, measured by AGE-Reader (Diagnoptics) and skin MVR [1.1-2.5]). Occurrence of hypoglycemic events showed an increasing trend (post-occlusive reactive hyperemia /PORH/), assessed by laser-Doppler among the UE. Among said patients, most were female (57.3 vs. 33.9% fl owmetry, were measured on the forearm in 23 T1D patients (43±13 yrs; p<0.02), younger (44 vs. 48 years), more sedentary (57.3 vs. 23.7% p<0.002) diabetes duration 18±9 yrs, HbA1C 8.4±1.0% /DCCT/) and 22 healthy controls and presented a higher insulinization rate (89.9 vs. 64.4% p<0.0004). Only (44±13 yrs). sRAGE was measured by ELISA kit. 56.2% had previously received any diabetes self-management education & PORH was lower in T1D patients compared to controls (490 ± 220% vs. training (DSME/T) vs. 69.5% among the working/active group. No statistically 630 ± 285%, p<0.05). Skin AF was higher in patients compared to controls signifi cant differences concerning comorbidities were found between both (2.28 ± 0.49 vs. 2.01 ± 0.47 U, p<0.05). Patients with higher skin AF (>2.3 U) groups. Predictive factors more frequently associated were: lack of food had lower skin MVR in comparison to patients with lower skin AF (<2.3 U) as intake (57%), drug overdose (30%) and 31.5% were unable to identify a expressed by PORH (320 ± 144% vs. 615 ± 202%, p<0.01). Importantly, PORH triggering cause. Out of surveyed population, 59.5% reported no immediate was inversely associated with skin AF (r=-0.74, p<0.001) as well as with consequences, 35.9% required use of additional reactive strips and 22.4% serum sRAGE concentration (r=-0.46, p=0.03). Skin microvascular reactivity reported social consequences. Out of total number of H events 56.5% refl ects the changes of the AGEs accumulation in the skin and serum sRAGE occurred among UE. In short, UE patients are 70% more likely to present concentration in T1D. Causal relationship is suspected and needs to be hypoglycemic events when measured against the employed population; food elucidated in the follow-up study. intake omission being the triggering event most commonly associated. This group exhibited a higher insulinization rate and less previous DSME/T. New approaches for the attention and care concerning this vulnerable patient group prove necessary.

COMPLICATIONS—MACROVASCULAR— ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

Guided Audio Tour: Translational Studies of Cardiovascular Disease in Diabetes I (Posters: 409-P to 416-P), see page 15.

& 409-P Tribble 3 Contributes to Foam Cell Formation and Programs Macro- phages towards Lipid Accumulation over Infl ammation DENNIS STEVERSON, JR., LING TIAN, YUCHANG FU, W. TIMOTHY GARVEY, Birmingham, AL Insulin resistance is central in the pathophysiology of cardiometabolic disease; however, common mechanisms t hat ex plain t he p ar allel development Supported By: Charles University of both type 2 diabetes and atherosclerosis have not been elucidated. We have previously shown that tribbles homolog 3 (TRB3) can exert a chronic & 411-P pathophysiological role in promoting insulin resistance in muscle and fat cells Metallothionein Prevents Diabetic Cardiomyopathy by Attenuation and also has an acute physiological role to alternatively regulate glucose of TRB3-mediated Cardiac Insulin Resistance uptake in fat and muscle during short-term fasting and nutrient excess. Since YI TAN, XIAOQING YAN, YUEHUI WANG, SHANSHAN ZHOU, CHI ZHANG, JUN TRB3 is expressed in human atherosclerotic plaques, we explored its role in ZENG, YONG LI, YAN LI, LU CAI, Louisville, KY, Changchun, China, Wenzhou, China foam cell formation to assess its potential contribution to atherogenesis. Cardiac insulin resistance is a key pathogenic factor for diabetic cardio- We have employed human THP-1 monocytes which transition to lipid-laden myopathy, but its mechanism remains largely unclear. Here we demonstrated macrophage foam cells when exposed to oxidized LDL (oxLDL). We fi rst that diabetes signifi cantly inhibited cardiac Akt phosphorylation from observed that TRB3 was upregulated by 2 fold increase (p<.01) within 24 hours 2 weeks to 2 months in wide-type (WT) mice, but not in cardiac-specifi c of treatment with oxLDL. To determine whether TRB3 actively participated in metallothionein-transgenic (MT-TG) mice. Cardiac Akt2 expression and foam cell formation, we overexpressed TRB3 in THP-1 monocytes and found phosphorylation was decreased and insulin-induced cardiac Akt2 and GSK- that this led to a 1.2-fold increase in cholesterol accumulation after 48 hour 3β phosphorylation and glycogen synthase dephosphorylation were also (p<.01) compared with control cells. This was due to increased expression of decreased in WT, but not MT-TG, diabetic mice. Deletion of the Akt2 gene

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A108 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES either in vitro H9c2 cells or in vivo signifi cantly impaired cardiac glucose plasma metabolomic patterns that distinguish T2D subjects at increased metabolic signaling. In addition, diabetes signifi cantly increased cardiac Akt risk of subsequent cardiovascular complications. These exploratory fi ndings negative regulator tribbles (TRB)3 expression only in WT mice, suggesting warrant validation in larger studies and a search for potential determinants the possible contribution of MT inhibition of diabetic up-regulation of TRB3 responsible for these alterations. to Akt2 function preservation. Cardiac H9c2 cells with and without forced MT-overexpression (MT-H9c2) were treated with tert-butyl hydroperoxide metabolite biochemical class fold difference q value (tBHP), which signifi cantly reduced Akt2 phosphorylation in both basal and N6-Threonylcarbamoyladenosine purine nucleoside/uremic solute 1.32 0.015 insulin-stimulating conditions only in H9c2 cells. Silencing TRB3 expression arabitol polyol/uremic solute 1.27 0.020 POSTERS with SiRNA completely prevented tBHP’s inhibition of insulin-stimulated Complications C-glycosyltryprophan amino acid derivative/uremic solute 1.23 0.016 Akt2 phosphorylation in H9c2 cells, while overexpression of TRB3 in MT- Acute and Chronic H9c2 cells completely abolished MT preservation of insulin-stimulated Akt2 1-stearoylglycerophosphoinositol Lysolipid 0.65 0.026 phosphorylation. Forced-overexpression of TRB3 by adenovirus-mediated 1-oleoylplasmenylethanolamine Lysolipid 0.69 0.026 gene delivery in MT-TG hearts also abolished MT’s preservation of cardiac 1-palmitoylplasmenylethanolamine Lysolipid 0.76 0.030 insulin signaling and prevention of diabetic cardiomyopathy. These results suggest that diabetes-attenuated cardiac Akt2 function via up-regulating Supported By: HL073168, P30DK036836, DK41526, DK67638, DK94292, TRB3 plays a critical role in diabetic inhibition of insulin signaling in the DK89503 heart. MT preserved cardiac Akt2-mediated insulin signaling by inhibiting TRB3, leading to the prevention of diabetic cardiomyopathy. & 414-P Supported By: ADA (1-11-BS-17, 1-13-JF-53); NSFC (81273509, 81200239, Leucine-Rich-Alpha2-Glycoprotein1 (LRG1) Is Reduced in Males 81061120517, QTJ13007) with Type 2 Diabetes Complicated with Peripheral Arterial Disease SUBRAMANIAM TAVINTHARAN, LI TING PEK, XIAOMENG WANG, SU CHI LIM, & 412-P LEE YING YEOH, CHEE FANG SUM, Singapore, Singapore Ethnic Disparities in Cardiovascular Risk Factors in Prediabetes: Peripheral arterial disease (PAD) occurs in about 15% of adults with type The African American Paradox 2 diabetes (T2D). In established PAD with limb ischaemia, surgical and SARA J. HEALY, TRUDY R. GAILLARD, KWAME OSEI, Columbus, OH endovascular revascularization are the main options,. Success in therapeutic Background: We have previously demonstrated paradoxical relationships angiogenesis (eg with VEGF) in animal has not been replicated in humans. between insulin sensitivity (Si) and lipids and lipoproteins in non-diabetic We explored the association of leucine-rich-alpha2-glycoprotein1 (LRG1), African Americans (AA). Therefore, the objective of this study was to a regulator of angiogenesis, with PAD, in T2D patients, hypothesizing that examine the clinical and metabolic characteristics of obese (OBS) AA and LRG1 is reduced in lower limb ischaemia. white Americans (WA) with prediabetes. We consecutively enrolled patients with T2D for the SMART2D program Methods: We studied 113 subjects (N=41 WA, 72 AA) with prediabetes from August 2011 to May 2013 (n=1604). Mean (1SD) age was 57.6 (10.7) (A1C>5.7% or fasting glucose >100mg/dl). We measured fasting and 2-hour years; diabetes duration 11.3 (8.8) years; 48.8% males; HbA1c 7.7 (1.3) %; 2 glucose, insulin, and c-peptide during OGTT. Fasting lipids, lipoproteins, eGFR 90.2 (34.9) mls/min/1.73m . infl ammatory marker (CRP), and HDL functionality (PON1) were measured. It is unknown if LRG1 is affected by renal clearance. Thus patients with 2 Insulin sensitivity (Si) was measured using FSIVGTT (MINIMOD). eGFR<60 mls/min/1.73m were excluded. To analyze the association of LRG1 Results: Mean age was similar (WA-46.4±12.7 vs. AA-46.5±10.4 yrs). with foot complications, we selected all males with peripheral neuropathy WA had lower BMI than AA (36.0±5.4 vs. 38.8±6.6 kg/m2, p=0.01). WA had (DPN, n=31) and PAD (n=51). Age-matched controls with no DPN or PAD were lower A1C (5.67±0.4 vs. 5.97±0.4%, p=0.0005). There were no differences randomly selected using SPSS version 21. Classifi cation according to ankle in glucose in WA vs. AA: fasting (101.2±10.1 vs. 97.4±12.3 mg/dl) and 120 brachial index (ABI) was: ABI ≤0.9 (PAD), 0.91-0.99 (Borderline), 1.00-1.40 minutes (127.9±46.2 vs. and 124.9±39.5mg/dl). WA had higher insulin at (Normal). ABI>1.4, considered as uncompressible vessels, were excluded. fasting (18.8±11.4 vs. 13.4±7.2uU/ml, p=0.013) and 120 minutes (114.8±83.2 Serum LRG1 levels were normally distributed. Those with PAD and vs. 90.7±58.4uU/ml). WA had higher c-peptide at fasting (3.98±1.7 vs. “Borderline” ABI had signifi cantly lower LRG1 than those “Normal” ABI (17.2, 2.67±0.9ng/ml, p=<0.0001) and 120 minutes (13.9±5.9 vs. 10.9±3.7ng/ml, 16.8 vs. 22.2 µg/ml; p=0.014). Endothelium-independent vasodilation was p=0.008). Mean Si was no different in WA vs. AA (2.88±2.34 vs. 2.84±1.69). reduced in the PAD and “borderline” groups when compared to “Normal” Serum cholesterol, HDL and LDL were similar. However, WA had higher ABI” group (p=0.051). Unlike PAD, male patients with DPN had no signifi cant triglycerides (125±55.5 vs. 84±46.9 mg/dl, p=0.002) despite comparable Si. difference in serum LRG1 (p=0.18). ApoA1 was lower in WA vs. AA (142.7±27.0 vs. 152.6±24.7, p=0.05). In conclusion, in males with PAD, LRG1 was signifi cantly reduced. Further Conclusion: We demonstrated metabolic paradoxes in A1C vs. glucose, research is needed to validate this association, explore if this association is Si vs. HDL, triglycerides, PON1 and ApoA1 in OBS AA with prediabetes. The indeed causal and whether increasing LRG1 activity at tissue level will help signifi cance of these paradoxical relationships in the CVD risk in OBS AA improve angiogenesis and potentially improve wound healing and functional warrants further elucidation. outcome in T2D patients with PAD. Supported By: NMRC

& 413-P Metabolomic Signatures of Increased Cardiovascular Risk in Type & 415-P 2 Diabetes Clinical Outcomes after Endovascular Revascularization in Type 2 MONIKA A. NIEWCZAS, CHRISTINE MENDONCA, ADAM M. SMILES, PAUL Diabetic Patients with Critical Limb Ischemia: Comparison of Direct COOPER, SUBRAMANIAM PENNATHUR, ANDRZEJ S. KROLEWSKI, ALESSANDRO and Indirect Revascularization According to the Angiosome Model DORIA, Boston, MA, Ann Arbor, MI ALBERTO PIAGGESI, ELISABETTA IACOPI, ALBERTO COPPELLI, IRENE BARGELLINI, The goal of this study was to identify metabolomic patterns associated with ANTONELLO CICORELLI, ALESSANDRO LUNARDI, CHIARA MATTALIANO, increased risk of cardiovascular disease (CVD) in type 2 diabetes (T2D). In a ELISABETTA LEPORATI, ROBERTO CIONI, Pisa, Italy nested case-control study of two T2D cohorts with preserved renal function The angiosome model (AM) is commonly used to guide bypass and at baseline, we determined the plasma metabolomic profi le at baseline endovascular procedures in the lower limb. We evaluated whether direct or in subjects who subsequently experienced CVD events (cases, n=81) as indirect revascularization, according to AM, may affect clinical outcomes in compared to those who did not (controls, n=79). CVD events were defi ned as diabetic patients with critical limb ischemia (CLI) undergoing percutaneous CVD death, non-fatal myocardial infarction or a revascularization procedure. trans-luminal angioplasty (PTA). Study subjects had (mean±SD): age=59±7 years, diabetes duration=15±9 We retrospectively evaluated 137 type 2 diabetic patients (M/F: 93/44; years, HbA1c=8.2±1.4%, eGFR=83±23 ml/min. Study follow-up was 7±3 age: 72.9±9.2 yrs; BMI: 27.7±8.2 Kg/m2 diabetes duration: 21.8±13.4 yrs; years. A total of 363 metabolites were detected in at least 66% of the study HbA1c 8.4±1.1%) consecutively admitted to our Department for CLI and subjects. After adjustment for multiple comparisons, 22 metabolites (16↑, foot lesions (FL) who underwent successful lower limb PTA. Patients were 6↓) were different between cases and controls (q value <0.05, see examples divided in 2 groups: direct (92 pts, 67%) or indirect (45 pts, 33%), depending in table). Nine of these were lipid metabolites, including 5 lysolipids. Of the on whether the fl ow to the artery directly feeding the site of ulceration, 13 non-lipid metabolites, 7 consisted of uremic solutes formerly shown to according to AM, was successfully acquired or not. Clinical outcomes (ulcer predict ESRD. Cluster analysis revealed two major clusters consisting of healing rate, major amputation or death) were compared in the two groups the signifi cant lipids and uremic solutes. In summary, we have identifi ed 3 months post PTA.

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A109 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

Healing rate was higher in direct vs. indirect group (58% vs. 30%, or its dominant negative, in the M restored the insulin signaling on p-AKT respectively, p<0.02). One major post-procedural amputation was necessary and VEGF secretion. Conversely, increasing PKC δ expression in the C Fib in the indirect group (2.2%) and none in the direct one. Mortality rate during by transfection with full length PKC δ isoform inhibited insulin’s activation the follow-up was 19% in direct vs. 31% in indirect group (p=NS). of p-Akt and VEGF secretion similar to Fib from M. Hyperglycemia and CVD Our data confi rm that direct revascularization of arteries supplying the FL can induce persistent activation of PKC δ to inhibit insulin’s effect on Fib to results in greater ulcer healing rate as compared to the indirect one. Thus, impair wound healing in diabetes. AM should be considered in diabetic patients with FL whenever possible.

POSTERS & 418-P Complications & 416-P The Phosphodiesterase Inhibitor Cilostazol Induces Regression of Acute and Chronic Effects of Antidiabetic Agents on Long-term Functional Outcome Carotid Atherosclerosis in Patients with Type 2 Diabetes Mellitus and Cardiovascular Events in Patients with Acute Ischemic Stroke SANGMO HONG, MOON SUK NAM, JEONG-TAEK WOO, YOUNG SEOL KIM, SEI KONSTANTINOS TZIOMALOS, STELLA BOUZIANA, MARIANNA SPANOU, MARIA HYUN BAIK, KWAN WOO LEE, JUN GOO KANG, DOO-MAN KIM, YONGSOO PAPADOPOULOU, VASILIOS GIAMPATZIS, PAVLINA KAZANTZIDOU, VASILIKI PARK, Gyeonggi, Republic of Korea, Incheon, Republic of Korea, Seoul, Republic of DOURLIOU, STAVROULA KOSTAKI, CHRISTOS SAVOPOULOS, APOSTOLOS I. Korea, Suwon, Republic of Korea, Chuncheon, Republic of Korea HATZITOLIOS, Thessaloniki, Greece Background: Antiplatelet drugs are effective in preventing recurrence It is unclear whether antidiabetic agents improve functional outcome and of atherosclerosis in type 2 diabetes (T2D) patients. However, the effi cacy reduce cardiovascular morbidity in patients with ischemic stroke. We aimed and usefulness of 2 different antiplatelet drugs, cilostazol and aspirin in the to evaluate the effects of different classes of antidiabetic agents on the progression of carotid intima-media thickness (IMT), a surrogate marker for long-term outcome of patients with acute ischemic stroke. We prospectively evaluating early atherosclerotic vascular diseases are unknown. studied 313 consecutive patients (36.4% males, age 78.5±6.3 years) who Methods: We conducted a prospective, randomized, open, blinded were discharged after acute ischemic stroke. After 1 year, patients and/ 36-month trial comparing the effects of cilostazol vs. aspirin in patients or their relatives were contacted by telephone and the functional outcome with T2D. A total of 421 T2D patients without any history of macrovascular was assessed with the modifi ed Rankin scale (mRS). At discharge, 75 complication, but with multiple conventional risk factors were randomly patients had type 2 diabetes mellitus (24.0% of the study population) and allocated to either an aspirin-treated (100 mg/d) group or a cilostazol-treated were treated with metformin (n=49), sulfonylureas (n=23), insulin (n=26), (200 mg/d) group. Patients underwent B-mode ultrasonography to assess dipeptidyl-peptidase IV inhibitors (n=10) and other antidiabetic agents (n=4), the IMT of the far walls of both common carotid arteries (CCA) annually. alone or in combination. Antidiabetic monotherapy was prescribed to 43 The primary outcome measure was the change in the mean carotid IMT of patients [metformin (n=18), sulfonylureas (n=7) and insulin (n=18)]. After 1 the right and left CCAs. Maximum IMT at the site with the greatest IMT year, the mRS score did not differ between patients prescribed monotherapy including plaques, was also sought. with metformin, sulfonylureas or insulin (2.3±2.1, 3.6±2.6 and 4.0±2.0, Results: The decrease in mean left, maximum left, mean right and respectively) and the incidence of cardiovascular events (cardiovascular maximum right IMT was signifi cantly greater with cilostazol compared death, myocardial infarction and stroke) also did not differ between the 3 with aspirin (-8.2±15.3% versus -3.5±14.7%, P=0.023; -8.0±19.6% versus groups (30.8, 42.9 and 41.2%, respectively). In contrast, patients treated -1.8±17.9, P=0.024; -8.9±16.7% versus -0.6±18.1%, P=0.001; -8.0±21.6% with metformin either alone or in combination with other antidiabetic agents versus -0.6±24.4%, P=0.025). In a regression analysis adjusted for potential had lower mRS score at 1 year than patients not treated with metformin confounding factors such as lipid profi les, HbA1c, body mass index, waist (2.4±2.2 vs. 3.9±2.2, respectively; p<0.05) even though cardiovascular event circumference, and anti-hypertensive medication, the improvements in CCA- rate did not differ between the 2 groups (31.6 vs. 41.7%, respectively). IMT with cilostazol treatment over aspirin treatment remained signifi cant. Neither the mRS score nor the incidence of cardiovascular events differed Conclusions: Cilostazol inhibited progression of carotid IMT in T2D between patients treated with sulfonylureas, insulin or dipeptidyl-peptidase patients potently in comparison with aspirin. The effect of cilostazol was IV inhibitors and patients not treated with these agents. In conclusion, independent of conventional cardiovascular risk factors. Cilostazol can be metformin appears to be associated with better functional outcome in another good viable option to reduce the risk of cardiovascular disease in patients with acute ischemic stroke. patients with T2D. Supported By: Korea Healthcare Technology R&D Project; Ministry of Health & Welfare Guided Audio Tour: Translational Studies of Cardiovascular Disease in Diabetes II (Posters: 417-P to 423-P), see page 15. & 419-P People with Type 2 Diabetes with Lower HbA1c Using Insulin & 417-P Experience Fewer Cardiovascular Events and Deaths: Results from Persistent Activation of PKC d and Inhibition of Insulin Actions in the CREDIT Study Fibroblasts from Type 1 Diabetes with CVD Impaired Wound Healing NICK FREEMANTLE, NICOLAS DANCHIN, FRANCOISE CALVI-GRIES, MARIE- MOGHER KHAMAISI, I-HSIEN WU, SAYAKA KATAGIRI, STEPHANIE HASTINGS, PAULE DAIN, MAYA VINCENT, PHILIP HOME, London, United Kingdom, Paris, HILLARY A. KEENAN, DENNIS P. ORGILL, GEORGE L. KING, Boston, MA France, Rezé, France, Newcastle upon Tyne, United Kingdom Abnormal fi broblast (Fib) functions are central causes of poor wound CREDIT (Cardiovascular Risk Evaluation in people with Type 2 Diabetes healing in diabetes. To identify potential mechanisms for diabetes induced on Insulin Therapy) was a noninterventional study designed to examine impaired wound healing, we studied cultured Fib derived from 25 subjects relationships between HbA1c and cardiovascular (CV) events in 2999 patients from the Joslin Medalist Study (M), who have had type 1 diabetes for 50 years beginning insulin in real-world practice in Europe, North America, and Asia, or longer and 7 age matched controls (C) without diabetes. Transplantation with up to 54 months’ follow-up. The study did not impact normal practice, of these Fib into full thickness dorsal wound of nude mice using membrane having no intervention or formal visits_instead, data were collected from showed that Fib from C signifi cantly enhanced epithelialization ratio of the physician reports. Primary outcome was the composite of nonfatal stroke wound (70% reduction at 9 days). However, Fib from M without history of or myocardial infarction or CV death. Events were blindly adjudicated by cardiovascular disease (CVD) was less effective (50% reduction), which was an endpoints committee. Relative hazard of CV events was described with even more impaired in Fib from M with CVD (38% reduction). Fib migration Cox proportional hazards models, including patient risk factors, and updated was reduced in the M by 2.5 fold compared to C. Elevating glucose levels mean HbA1c as a time-dependent covariate. Primary outcome components from 5.6 to 25 mM for 8h caused signifi cant reduction in cell migration in were described separately. The relationship of severe and symptomatic both C (p=0.03) and in the M (p<0.05), which was normalized by incubation hypoglycemia (collected observationally for prior 6 months) with CV and all- with PDGF, but not with insulin. Insulin induced expressions of VEGF mRNA cause mortality was examined by adding patient-level covariates to the Cox and protein in Fib from M with or without CVD were decreased by 50% and models. 75% respectively vs. C. General inhibitors of protein kinase C (PKC) and its In total, 147 primary events were accrued during study follow-up. There δ isoform, but not the β isoform restored insulin effect on VEGF secretion were 60 CV deaths, 44 nonfatal MIs, and 57 nonfatal strokes, with 148 all- in the M to C. Similarly, insulin, not PDGF’s, activation of p-AKT, but not cause deaths. There was a signifi cant positive relationship between updated p-ERK was reduced by 55% in the M vs. C. Expression of PKC δ protein mean HbA1c and primary outcome; hazard ratio (HR) 1.25 (95% CI: 1.12-1.40; were increased in the M vs. C by 3.5 fold and M with CVD was 2 fold higher P<0.0001). CV death (HR 1.31 [1.10-1.57]; P=0.0027) and stroke (HR 1.36 [1.17- than M without CVD. No signifi cant change in PKC α, β1, and β2 protein 1.59]; P<0.0001) were both strongly associated with HbA1c, but myocardial expression compare to C were observed. Knockdown of PKC δ by siRNA infarction was not (HR 1.05 [0.83-1.32]). One or more severe hypoglycemic

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A110 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES episodes affected 175 participants, while 1508 experienced ≥1 symptomatic degradation and impairs functionality of HDL in vivo and likely contributes hypoglycemic event. We found no relationship between history of severe or signifi cantly to increased risk of CVD in diabetes. symptomatic hypoglycemic events and CV or all-cause death. Supported By: BHF Thus, as measured in the CREDIT study, ongoing poorer glucose control was associated with CV events; hypoglycemia was not associated with CV & 422-P or all-cause death. A DPP-4 Inhibitor Suppresses Plaque Formation in the Aorta and Supported By: Sanofi Coronary Arteries with Decrease of Macrophage Infi ltration in

Cholesterol-Fed Rabbits POSTERS & 420-P TSUTOMU HIRANO, SATOKO YAMASHITA, MASAKI TAKAHASHI, HIROYUKI Complications Glucose Management in a Cluster Randomized Trial of Evidence- HASHIMOTO, MORITAKA GOTO, Tokyo, Japan, Mie, Japan Acute and Chronic based Treatment Protocols for Acute Stroke (QASC) Several studies have demonstrated suppression of atherosclerosis by N. WAH CHEUNG, CHRIS LEVI, PATRICK MCELDUFF, JEANETTE WARD, JEREMY dipeptidyl peptidase-4 (DPP-4) inhibitors in hypercholesterolemic mice. M. GRIMSHAW, SIMEON DALE, CATHERINE D’ESTE, RHONDA GRIFFITHS, However, it remains unknown whether DPP-4 inhibitors might also exert CLARE QUINN, PETA DRURY, MALCOLM EVANS, DOMINIQUE CADILHAC, anti-atherogenic effects in bigger animals. We examined the effect of SANDY MIDDLETON, Sydney, Australia, Newcastle, Australia, Ottawa, ON, Canada, anagliptin, a DPP-4 inhibitor, on the development of atherosclerosis in the Melbourne, Australia aorta and coronary arteries in rabbits. Japanese White rabbits fed a diet The Quality in Acute Stroke Care (QASC) trial was the fi rst study to containing 0.5% cholesterol were given anagliptin (0, 1 or 3 mg/ml, mixed demonstrate a reduction in death and dependency following stroke with a in drinking water; n=16-18 each) for 12 weeks. Dietary cholesterol increased treatment protocol which included glucose control (1). The other elements of the serum LDL-cholesterol level to over 1000 mg/dl. No signifi cant changes of the protocol package were fever and swallowing management. the body weight, water intake, serum lipids, HbA1c or the glucose response QASC was a single blind cluster randomised trial with acute stroke to intravenous glucose loading were observed following administration of units (ASUs) randomized to control (n=9) or an intervention (n=10) utilizing anagliptin. The plasma DPP-4 activity was suppressed by up to 84%, and the treatment protocols for hyperglycemia, fever and swallowing management. active GLP-1 levels doubled. Dietary cholesterol resulted in the development of The glucose protocol comprised an algorithm for regular glucose monitoring severe atherosclerosis in the aorta, with a ratio of the plaque to the total aortic and hyperglycemia management (including insulin infusion if glucose level surface areas of 22±10%. Anagliptin at 1 and 3 mg/ml suppressed the plaque ≥11 mmol/L for patients with diabetes, and ≥16 mmol/L for patients with ratio to 18±11 and 9±8% (p<0.001), respectively. Mild atherosclerotic lesions new onset hyperglycemia) for the fi rst 72 hours. The current sub-analysis were observed in the coronary arteries of cholesterol-fed rabbits. Anagliptin examines the predictive value of glucose parameters for 90-day death and decreased both the intima and media areas, and decreased the intima/media dependency (modifi ed Rankin Scale [mRS] ≥2). ratio in the coronary arteries. Notably, the macrophage-positive area in the 19 ASUs with 1126 subjects participated in the study. There was a reduction coronary arteries was suppressed by 78% (p<0.05) with anagliptin. The ratio in death and dependency at 90 days in the intervention ASU subjects (42% of macrophage area to the plaque area was also substantially decreased by vs. 58%, p=0.002). The mean glucose was 7.0±2.0 mmol/L in the intervention 83%. Additionally, arterial TNF-α mRNA expression was reduced following and 6.8±1.8 mmol/L in the control ASU subjects (absolute difference 0.54, administration of anagliptin. Our study demonstrated for the fi rst time that a 95%CI 0.08-1.01, p=0.02). Patients with a lower mean glucose in the fi rst DPP-4 inhibitor suppressed the development of atherosclerosis, including in 72 hours of admission (p=0.003); those who had a formal venous glucose the coronary arteries, even in bigger animals, suggesting the potential of DPP- measurement taken in the Emergency Department (p=0.05); and those who 4 inhibitors to inhibit coronary atherosclerosis also in humans. had at least one fi nger prick glucose in the fi rst 72 hours of admission to an ASU (p=0.03) were signifi cantly less likely to be dead or dependent 90-days & 423-P post stroke. More patients dead or dependent at 90-days had at least one Impact of Gender on the Risk of Coronary Atheroscerosis and fi nger prick blood glucose reading >11mmol/L (p=0.02). Cardio vascular Events Conferred by HbA1c in Subjects without Implementation of a protocol which included glucose control improved Known Diabetes stroke outcomes. Patients who were alive and independent 90-days post CHRISTOPH H. SAELY, ALEXANDER VONBANK, DANIELA ZANOLIN, PHILIPP stroke were more likely to have been managed in accordance with elements REIN, HEINZ DREXEL, Feldkirch, Austria, Triesen, Liechtenstein, Philadelphia, PA of the glucose protocol. Diabetes confers a larger increase in the relative risk of cardiovascular Reference: 1. Middleton S, et al. Lancet 2011; 378 (9804): 1699-1706. events among women than among men. Whether gender also affects the association of HbA1c with coronary atherosclerosis and cardiovascular & 421-P events among subjects without known diabetes is unknown. Methylglyoxal Modifi cation Is Linked to Decreased Plasma Con cen- We enrolled a large consecutive series of 1479 patients undergoing tra tion and Functionality of HDL in Diabetes and Insulin Resistance coronary angiography for the evaluation of established or suspected NAILA RABBANI, LISA GODFREY, NAOMI YAMADA-FOWLER, PAUL J. coronary artery disease (CAD), including 495 women and 984 men who did THORNALLEY, Coventry, United Kingdom, Warwick, United Kingdom not have previously known diabetes Signifi cant CAD was diagnosed in the Decreased plasma concentration of high density lipoprotein cholesterol presence of signifi cant coronary stenoses ≥50%. Prospectively, we recorded (HDL C) is linked to increased risk of cardiovascular disease (CVD) in cardiovascular events over 4.4±1.2 years. diabetes. Decreased anti-atherogenic properties of high density lipoprotein Among women, 36.4%, 56.2%, and 7.4% and among men 44.2%, 46.6%, (HDL) is also implicated in increased CVD risk. The extent of modifi cation and 9.1% had HbA1c values of <5.7% (normal according to ADA criteria), of HDL by methylglyoxal, a reactive dicarbonyl metabolite, in patients with 5.7-6.4% (at risk of diabetes according to ADA criteria), and ≥6.5% (diabetes diabetes and related functional effects is unknown. The aim of this study according to ADA criteria), respectively. The prevalence of angiographically is to quantify glycation damage to HDL in healthy people and patients diagnosed signifi cant CAD in these HbA1c categories was 31.2%, 38.2%, with type 2 diabetes and to characterise atherogenic properties. HDL was and 47.2% among women (ptrend = 0.041) and 63.2%, 65.3% and 64.8% isolated from healthy human subjects and patients with type 2 diabetes. among men (ptrend = 0.589). An interaction term gender x HbA1c was HDL was delipidated and hydrolysed enzymatically to component amino statistically signifi cant (p<0.001), indicating that the association of HbA1c acids and glycated amino acid content was determined by stable isotopic with CAD was signifi cantly stronger among women than among men. During dilution analysis liquid chromatography-tandem mass spectrometry. HDL follow-up, the incidence of cardiovascular events was 21.5% in women and modifi cation by methylglyoxal and related dicarbonyl metabolites accounted 28.5% in men (p=0.002). Among women, HbA1c strongly and signifi cantly for 2.5% HDL in healthy people (n = 22), increasing to 4.5% in patients with predicted cardiovascular events (adjusted OR for a 1% increase in HbA1c type 2 diabetes (n = 7). When HDL was modifi ed by methylglyoxal in vitro to (HR 2.08 [1.24-3.03]; p<0.001), but not among among men (HR 1.12 [0.94- similar extents (1.8-2.6 molar equivalents of MG-H1), the sites of modifi cation 1.53]; p=0.145). An interaction term gender x HbA1c again was statistically by MG identifi ed by mass spectrometric peptide mapping were arginines-27, signifi cant (p=0.011), indicating that HbA1c was a signifi cantly stronger -123 and -149. Modifi cation by methylglyoxal decreased HDL particle size predictor of cardiovascular events among women than among men. (-16%, <0.001) and plasma half-life (45%, P<0.001) in vivo. We also found We conclude that gender signifi cantly modulates the risk of coronary MG modifi cation of HDL inhibited the exchange of cholesteryl ester by atheroscerosis and cardiovascular events conferred by HbA1c in subjects CETP. Kinetic modelling predicted dicarbonyl modifi cation produces a 2- 6% without known diabetes. decrease in total plasma HDL and up to 5 - 13% decrease in functional HDL in Supported By: Austrian National Bank patients with type 2 diabetes. Methylglyoxal modifi ed glycation accelerates

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A111 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

424-P We analyzed the relationships between baseline blood pressure parameters Osteoprotegerin Trumps Osteocalcin in Association with Arterial and subsequent fi rst fatal or non-fatal stroke events in 595 patients with Calcifi cation in Diabetes type 2 diabetes who participated in the epidemiological study CARDIPP M. JAMES LENHARD, RAELENE E. MASER, MICHAEL B. SNEIDER, Newark, DE (Cardiovascular Risk Factors in Patients with Diabetes - a Prospective Study Coronary artery calcifi cation (CAC) is a prominent feature of athero- in Primary Care). Study participants were treated in usual care at their primary sclerosis and is associated with cardiovascular events. In vitro studies health care centers, and were followed until a fi rst stroke occurred or until 31 have suggested that osteoprotegerin (OPG) and osteocalcin (OC) exert anti- December 2012. No patients were lost to follow-up. Offi ce and 24-hour ambulatory pulse pressures were successfully

POSTERS calcifi cation potential in the vessel wall. Increased serum OPG levels have

Complications been shown to be associated with increased CAC scores in type 2 diabetes measured at baseline in 608 patients. We excluded 13 patients who reported Acute and Chronic (T2D); whereas decreased serum OC levels were found for diabetic and a history of previous stroke, leaving 595 patients available for analysis, of non-diabetic patients who had an increased number of stenotic coronary which 18 had a stroke during follow-up (median follow-up time: 6.1 years). arteries. Undercarboxylated OC (ucOC) may affect glucose homeostasis and There was no signifi cant relationship between stroke risk and offi ce pulse was shown to be associated with abdominal aortic calcifi cation in men. In pressure (p=0.11), but ambulatory pulse pressure predicted stroke risk this study, we examined serum OPG, intact OC, and ucOC levels to determine signifi cantly (p=0.01). The unadjusted hazard ratio per 5 mmHg increase of which biomarker was more strongly associated with CAC. Fifty individuals ambulatory pulse pressure was 1.29 (95% CI: 1.06-1.58). This association with T2D (age=63±10 yrs, duration=13±8 yrs) were examined. CAC imaging remained signifi cant (p=0.01) in a Cox regression model that adjusted for was performed by multidetector computed tomography and CAC scores age, sex, diabetes duration and antihypertensive and statin medication at ≥10, expressed in Agatston units, were considered abnormal. OC, ucOC and baseline (adjusted hazard ratio per 5 mmHg increase of ambulatory pulse OPG levels were determined by ELISA. Abnormal CAC scores were found for pressure: 1.33, 95% CI: 1.07-1.65; n=558). 64% of the study cohort. OPG levels were signifi cantly elevated (5.5±2.0 vs. Ambulatory pulse pressure predicted stroke events in patients with 4.2±1.7 pmol/L, p<0.05) for those with abnormal CAC scores. No univariate type 2 diabetes, but offi ce pulse pressure did not. Our data support a more differences were found for OC or ucOC. Logistic regression revealed that widespread utilization of ambulatory blood pressure measurements in an increase in serum OPG was signifi cantly associated with an increase in patients with type 2 diabetes for the purpose of stroke risk assessment. CAC (odds ratio, 2.8; 95% confi dence interval, 1.4-5.9). Duration (p<0.05), gender (p<0.01), systolic BP (p<0.05), and HOMA-IR (p=0.054) were included 427-P as covariates in the model (Nagelkerke R2=0.59). Neither OC or ucOC were independent correlates in the model. In the vascular, OPG and OC are reported WITHDRAWN to act as protective factors inhibiting CAC. Paradoxically elevated serum OPG appears to indicate increased vascular damage whereas increased OPG in the vascular may be a compensator mechanism to limit damage. Our results suggest that OPG is a more useful serum biomarker than OC or ucOC for identifying those at increased risk of CAC in T2D.

425-P Osteoprotegerin Is Related to Arterial Stiffness in Patients with Type 2 Diabetes IOANNA ELEFTHERIADOU, PINELOPI GRIGOROPOULOU, IORDANIS MOUROUZIS, ALEXANDER KOKKINOS, DESPOINA PERREA, NICHOLAS KATSILAMBROS, KONSTANTINOS MAKRILAKIS, NICHOLAS TENTOLOURIS, Athens, Greece Pulse wave velocity (PWV) of the carotid-femoral (cf) arteries has emerged as a new marker and predictor of total cardiovascular risk. Recent data suggest that serum osteoprotegerin (OPG) is a new risk factor for the progression of atherosclerosis and vascular dysfunction in diabetes. The purpose of this study was to determine the relationship between PWVcf and serum OPG levels in patients with type 2 diabetes (T2DM). A total of 67 patients with T2DM were recruited (mean age 67.8±8.7 years, mean diabetes duration 15.4±10.7 years). PWV was measured at the carotid-femoral segment. Serum OPG levels were measured using Luminex Multiplex assay. OPG levels were signifi cantly associated with PWVcf (r=0.433, p<0.001). Patients with PWVcf values higher than the median value (11.8m/s) had signifi cantly higher OPG levels in comparison with patients with PWVcf values lower than the median value (731.2±279.8 vs. 594.8±232.2 pg/ ml, p=0.002). Univariate linear regression analysis demonstrated that age (β-coeffi cient=0.330, p<0.001), male gender (β-coeffi cient=0.244, p=0.005), arterial hypertension (β-coeffi cient=0.218, p=0.011) and OPG levels (β-coeffi cient=0.420, p<0.001) were signifi cantly associated with PWVcf. No signifi cant associations were found with diabetes duration, smoking, 428-P BMI, dyslipidemia and HbA1c. Multivariate linear regression analysis, after Dysregulation of Human Telomerase Reverse Transcriptase and adjustment for age, diabetes duration and arterial hypertension, showed that Leukocyte Telomere Length Are Major Determinants of Circulating PWVcf was signifi cantly associated with male gender (β-coeffi cient=0.236, Biomarkers of Infl ammation and Oxidative Stress in Patients with p=0.003) and OPG levels (β-coeffi cient=0.322, p=0.001). Type 2 Diabetes Mellitus Serum OPG levels are strongly associated with PWVcf irrespective of NABILLA ABDELLA, RASHA AL KHALDI, FAHAD AL MULLA, OLUSEGUN MOJI- traditional cardiovascular risk factors. MINIYI, Safat, Kuwait, Kuwait, Kuwait In Type 2 Diabetes mellitus (T2DM), shorter telomeres could be due 426-P to inherited shorter length or to telomere attrition caused by low grade Ambulatory Pulse Pressure Predicts Fatal and Nonfatal Strokes in infl ammation, metabolic perturbations or oxidative stress. There are no Patients with Type 2 Diabetes studies on role of telomerase, an enzyme that prevents telomere attrition. MAGNUS WIJKMAN, TORBJÖRN LINDSTRÖM, TOSTE LÄNNE, CARL JOHAN This study evaluates the associations of leukocyte telomere length (LTL) ÖSTGREN, FREDRIK H. NYSTROM, Norrköping, Sweden, Linköping, Sweden with human Telomerase Reverse Transcriptase (hTERT), cardio-metabolic High pulse pressure measured by ambulatory blood pressure monitoring risk factors, biomarkers of oxidative stress and infl ammation in patients is associated with increased mortality risk in patients with diabetes. It is not with T2DM. BMI, Waist Circumference (WC), fasting glucose, insulin, lipid known, however, whether high ambulatory pulse pressure is also associated profi le, HbA1c, hTERT, Myeloperoxidase [MPO], Malondialdehyde [MDA], Total with increased stroke risk in patients with diabetes. Oxidative stress status [TOS] and LTL were measured in 225 T2DM patients

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A112 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES and 245 controls. Insulin resistance [IR] was estimated with the Homeostasis were correlated with baPWV values (r = 0.3400, p < 0.0001) in NGT subjects. Model Assessment [HOMA-IR]. T2DM patients had signifi cantly (p<0.0001) (5) When NGT subjects were divided into three groups: group 1 (1h PG < 8.56 lower LTL compared to controls [(Mean±SD:2.1±0.24) vs. (Mean±SD:4.1±0.14)] mmol/L, N=1595), group2 (8.56 < 1h PG < 10.17 mmol/L, N=334), and group respectively. hTERT was higher in controls compared to T2DM patients 3 (10.17 mmol/L < 1h PG, N=130), baPWV of group 3 (1473 + 322 cm/s) was [(Mean±SD: 32.9±8.9 ng/mL) vs. (Mean±SD: 21.4±4.7 ng/mL)]. LTL correlated signifi cantly higher than that of group 2 (1355 + 252 cm/s) and baPWV of group negatively with age [r = -0.20, p=0.009], BMI [r = -0.33, p=0.006], WC [r = 2 was also signifi cantly higher than that of group 1 (1275 + 212 cm/s). -0.31, p<0.0001], and Insulin [r = -0.16, p=0.03]. The signifi cance of these Conclusions: IGT, but not IFG, is a risk factor for early-stage atherosclerosis. correlations were maintained after corrections for age and sex but not after Surprisingly, higher 1h PG level is a risk factor for early-stage atherosclerosis POSTERS correction for BMI. Binary logistic regression showed that higher BMI [OR=2.4] in NGT. Complications and WC [(OR=2.4] were associated with higher risk of short LTL. Shorter LTL Acute and Chronic was signifi cantly associated with higher risk of T2DM [OR=7.5] whereas higher 431-P hTERT levels were associated with lower risk of T2DM [OR=0.88]. Telomere Is Home Blood Pressure Reporting in Patients with Type 2 Diabetes shortening in T2DM is, in part, due to obesity dependent mechanisms related Reliable? to infl ammation and oxidative stress. Associated defi ciency of protective SAORI MAJIMA, MICHIAKI FUKUI, SHINOBU MATSUMOTO, EMI USHIGOME, telomerase amplifi es cardio-metabolic risk. KANAE MATSUSHITA, TAKAFUMI SENMARU, MASAHIDE HAMAGUCHI, MAI Supported By: College of Graduate Studies (YM06/11) ASANO, MASAHIRO YAMAZAKI, GOJI HASEGAWA, NAOTO NAKAMURA, Kyoto, Japan 429-P Home blood pressure (HBP) monitoring is a valuable tool in the management Retinal Biomarkers as a Potential Tool for the Detection of Coronary of hypertension. To our knowledge no study has investigated the reliability Heart Disease in Patients with Type 2 Diabetes of HBP measurements in patients with type 2 diabetes. The aim of this study YAWEI VIVIAN GUO, BENNY ZEE, HARRIET CHUNG, RISA OZAKI, WING-YEE SO, was to evaluate the reliability of HBP reporting and determine the factors ANDREA O. LUK, PHILIP LI, AUGUSTINE LAM, JACK LEE, JULIANA C. CHAN, Hong that affected it in patients with type 2 diabetes. A total of 280 patients were Kong, China requested to measure triplicate morning and evening HBP using a digital Coronary heart disease (CHD) is the leading cause of death in the world. It automatic BP monitor and to record these measurements in a logbook over is a common macrovascular complication of diabetes. Pathological changes a 2-week period. The patients were not informed of the storage function of of CHD have also been shown to occur in retina, which is more accessible their BP monitor. The concordance rate between the self-reported data in for direct imaging. Previous reports have shown that retinal characteristics, the logbook and the stored data in the monitor was 78.6%. Although 144 such as vessel diameter and tortuosity, were related with both prevalent of the patients (51.4%) had more than 90% concordant data, 44 (15.7%) had and incident of CHD. In this study, we would like to investigate whether 50% or less concordant data. The self-reported data were signifi cantly lower the changes of retinal biomarkers are potential tools for classifying CHD than the stored data (mean morning systolic BP: 129.8 ± 15.8 vs. 130.6 ± 16.2 patients from those without. mmHg, p < 0.0001). In addition, logbook BP was less variable than monitor We carried out a case-control study with 55 CHD and 55 age- and sex- BP (SD of morning systolic BP: 7.9 ± 3.2 vs. 9.8 ± 3.5 mmHg, p < 0.0001). matched controls from the Joint Asia Diabetes Evaluation (JADE) program. In The most frequent erroneous data (55.8%) were “selected data” which addition to demographic, clinical data and retinal images, 23 retinal vascular were selected randomly from multiple measurements, and the second most biomarkers related with changes of vessel diameter, tortuosity, branching erroneous (23.3%) were “fi ctional data” which were not in the monitor. The pattern and bifurcation, were measured using a semi-automated computer- concordance rate correlated signifi cantly with hemoglobin A1c (β = -0.156, assisted image program (Singapore I Vessel Assessment or SIVA). Logistic p = 0.0149) and current smoking (β = -0.165, p = 0.0184). Urinary albumin regression models using clinical risk factors and retinal characteristics were excretion also correlated with the SD of morning systolic BP in the monitor, established. The performances of different models were compared using but not with that in the logbook. In conclusion, patients with type 2 diabetes area under curve (AUC). sometimes report erroneous HBP, especially those with poor glycemic In the traditional risk factor model, hypertension, total cholesterol, BMI, control or a smoking habit. As a result of this inaccurate reporting, HBP waist circumference and HbA1c were included, which yielded an AUC of control obtained from logbooks may appear better than that obtained from 0.76 (95% CI 0.67-0.85), with sensitivity, specifi city and accuracy of 70.9% a monitor. A device capable of automatically saving BP data may be helpful respectively. The performance of a model only using retinal characteristics for obtaining accurate measurements of HBP that will assist in providing was similar to the traditional risk factor model, with sensitivity of 69.1%, optimal treatment for hypertensive patients with type 2 diabetes. specifi city of 72.7%, accuracy of 70.9% and AUC of 0.74 (0.65-0.84). However, combination of the traditional risk factors and retinal characteristics can 432-P improve the performance with sensitivity of 75.9%, specifi city of 75.9%, Fetuin-A Acts on the Expression and Secretion of (Pro)-infl ammatory accuracy of 75.9%, and yielded an AUC of 0.84 (0.77-0.92). and Angiogenic Factors in Perivascular Fat Cells via Different Retinal characteristics provide useful information that contributes as a Signalling Pathways potential tool for identifying CHD cases in patients with type II diabetes. DOROTHEA I. SIEGEL-AXEL, SUSANNE ULLRICH, NORBERT STEFAN, KILIAN RITTIG, FELICIA GERST, ULRIKE SCHMIDT, BIRGIT SCHREINER, HANS-EBERHARD 430-P SCHALLER, HANS-ULRICH HAERING, Tübingen, Germany A New Aspect of 75-g Oral Glucose Tolerance Test for Estimation Previously we found that fetuin-A has several functions critically of Atrial Stiffness important to cardiovascular health, as effects on (pro)infl ammatory and SHUICHI OKADA, TSUGUMICHI SAITO, EIJIRO YAMADA, YOKO SHIMODA, YUKO angiogenic factors of perivascular fat cells (PVFC): in contrast to the TLR4- TAGAYA, MASANOBU YAMADA, Maebashi, Japan dependent stimulation of fetuin-A/palmitate (fet/palm) on IL-6 and -8, the Aims: The study aimed to investigate early-stage atherosclerosis in patients inhibition of HGF was mediated via the insulin-dependent receptor tyrosine with impaired fasting glucose (IFG) compared to patients with impaired glucose kinase pathway. Here, fet/palm induced signalling pathways downstream tolerance (IGT) and normal glucose tolerance (NGT) subjects. TLR4 were studied in PVFC more detailed. Methods: Body mass index, systolic blood pressure, fasting plasma PVFC were isolated from specimens around arm arteries of patients from glucose, lipid parameters, ankle-brachial pressure index and brachial-ankle the BG Trauma Center. Cells were treated with or without the JNK inhibitor pulse wave velocity (baPWV) were measured in 2842 subjects. The subjects SP500125 (10 µmol/L), the p38MAPkinase inhibitor SB203580 (10 µmol/L), were divided into the following 5 groups based on a 75-g oral glucose the MEK1/2 inhibitor PD98059 (10 µmol/L) and the NFκB inhibitor BAY11- tolerance test: (i) normal fasting plasma glucose (FPG)/normal glucose 7082 (5 µmol/L) 2 h prior to the addition of fet (600 µmol/L) and palm (50 tolerance group (NGT), (ii) impaired fasting glucose group (IFG), (iii) impaired µmol/L). After 24 h protein release was quantitiated by luminex and/or ELISA glucose tolerance group (IGT), (iv) combined glucose intolerance group (CGI) and mRNA expression by realtime PCR. and (v) diabetic glucose intolerance group (DM). IL-8, IL-6 and MCP-1 mRNA expression and protein release were signifi cantly Results: (1) IGT, CGI and DM groups had signifi cantly higher baPWV values upregulated by fet which was potentiated by palm. MEK1/2 and p38MAPkinase compared with NGT and IFG groups. (2) baPWV values were signifi cantly inhibition had no effect whereas the NFκB and JNK inhibitor caused a 30-40% correlated with FPG levels and two hours post-challenge glucose (2h PG) blockade. In contrast, HGF was strongly inhibited by fet/palm but this was not levels. (3) However, multiple regression analyses showed an independent infl uenced by any of the inhibitors. However, the angiogenic factor bFGF was association of age, systolic blood pressures, total cholesterol, and not FPG but not inhibited but stimulated and this was only infl uenced by the JNK inhibitor. 2h PG with baPWV values. (4) One hour post-challenge glucose (1h PG) levels Finally, fet/palm exerted only slight effects on the angiogenic factor VEGF.

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A113 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

Fet/palm caused strong stimulatory effects on (pro)infl ammatory proteins. 434-P However, effects on angiogenic factors were diverse: HGF was inhibited, Dual Evaluation of Max-Intima-Media Thickness and Mean-Intima- bFGF stimulated and VEGF remained nearly unchanged. Blockade with several Media Thickness May Be Useful in Estimating Coronary Artery signalling pathway inhibitors showed that fet acts via different pathways Stenosis downstream TLR4 receptor activation, as JNK or NFκB. Nevertheless, the KOJI KASHIMA, MICHIKO KAWASAKI, HIROYUKI SHIMIZU, MASANOBU effects on angiogenic proteins seem to be mediated by totally other, TLR4- YAMADA, Kiryu, Japan, Ohtawara, Japan, Maebashi, Japan independent pathways. Objective: Cardiovascular disease remains a leading cause of death in Supported By: German Federal Ministry of Education and Research; German

POSTERS patients with diabetes. Non-invasive, effi cient methods are required to

Complications Center for Diabetes Research identify the high risk patients. We examined the relationship between the Acute and Chronic severity of coronary stenosis and carotid artery intima-media thickness 433-P (IMT) in 103 subjects who both done with 128 multi-slice computed Activin A Is Associated with Higher Extent of Coronary Artery tomography coronary angiography and carotid artery ultrasonography. Disease (CAD), but Not with Increased Rate of Progression During 7 Methods: All subjects were divided by the severity of coronary artery Years Follow-up, in Subjects with Type 2 Diabetes stenosis into 4 categories; no (≥0%),mild (≥25%),middle (≥50%),and severe ANNE PERNILLE OFSTAD, GEIR R. ULIMOEN, ELSA ORVIK, KNUT ENDRESEN, (≥75%) stenosis. Mean-IMT was calculated from the values measured KÅRE I. BIRKELAND, THOR UELAND, PÅL AUKRUST, LARS GULLESTAD, ODD ERIK at 6 points of common carotid artery. Results: 1) Max-IMT values were JOHANSEN, Bærum, Norway, Oslo, Norway signifi cantly higher in the middle stenosis group (2.52±0.82mm,p=0.004), Silent CAD is prevalent among type 2 diabetes (T2D) subjects. Previous and the severe stenosis group (2.65±0.94mm,p=0.010) than no stenosis studies showed that the infl ammatory marker Activin A (ActA) is associated group (1.93±0.80mm). And mean-IMT values were signifi cantly higher in with CAD in T2D. We hypothesized that ActA would be related to the extent the middle stenosis group (1.04±0.25mm,p=0.004), and the severe stenosis and progression of CAD evaluated by invasive coronary angiography (CA) in group (1.06±0.25mm,p=0.008) than no stenosis group (0.87±0.20mm). 2) DM asymptomatic T2D patients. or IGT(impaired glucose tolerance) existed in 24.2% and 6.1% in no stenosis Fifty-one T2D patients (11 female, mean±SD age 58±8 years [yrs],diabetes group, 52.6% and 0.0% in mild stenosis group, 32.4% and 8.1% in middle duration 7±7 yrs, HbA1c 7.4±1.5%, LDL 2.8±0.9 mmol/L, blood pressure stenosis group and 57.1% and 7.1% in severe stenosis group.3) Estimating 141±19/83±9 mmHg) with ≥1 additional cardiovascular risk factor underwent the existence of ≥50% coronary stenosis by max-IMT (cut off point 2.5mm), CA,laboratory and clinical assessment at baseline (BL) and 7 yrs follow- sensitivity was 62.8%, and specifi city 59.7%, and by mean-IMT (cut off point up. We explored the relation between the extent of CAD (i.e. no, 1-, 2-, 1.0mm), 62.5% and 61.4%, respectively. 4) Signifi cant coronary stenosis or 3-vessel [v] CAD defi ned as ≥ 50% luminal stenosis in major coronary (≥50%) was found in 71.4%(15/21) of patients with max-IMT≥2.5mm and arteries) and the CAD trajectory (i.e. no change, progression, or regression) mean-IMT≥1.0mm, whereas 30.6%(11/36) of patients without max-IMT≥ according to median levels of ActA. 2.5mm or mean-IMT≥1.0mm. In the cases of only max-IMT ≥2.5mm or Median (IQR) ActA was 0.53 (0.38, 0.67) ng/mL. At BL, six (12%) had 1-v and mean-IMT≥1.0mm, signifi cant stenosis was found in 52.4%(11/21) and 5 (10%) had 2-or 3-v CAD, whereas at 7 yrs, ten (20%) had 1-v and 8 (16%) had 56.0%(14/25), respectively. Conclusion: Evaluation of max-IMT with mean- 2-or 3-v CAD. When stratifi ed by median ActA (Table 1), the ActA>median IMT may be useful in estimating the possibility of coronary artery stenosis group had more extensive CAD at BL and a trend towards more at 7 yrs. The in diabetic patients. progression of CAD during 7-yrs was not infl uenced by BL levels of ActA. Higher levels of ActA are associated with more extensive CAD in T2D, but 435-P do not seem to increase progression rate as judged by invasive CA. Carotid Artery Plaque and Apolipoprotein B to Apolipoprotein A-I Ratio Predict Cerebrovascular Stenosis in Asymptomatic Patients with Type 2 Diabetes HEE SUN KWON, JANG WON SON, SEONG-SU LEE, SUNG RAE KIM, SOON JIB YOO, JI KYEONG SHIN, Seoul, Republic of Korea, Bucheon, Republic of Korea Diabetes mellitus (DM), as a strong risk factor of atherosclerosis, is associated with coronary artery disease (CAD) and ischemic stroke. Common carotid artery intima-media thickness (CCA-IMT) is considered as a surrogate marker of atherosclerosis and is used for a primary prevention of CAD. But CCA-IMT is used as a secondary prevention in ischemic stroke restrictively. This cross sectional study assessed CCA-IMT cut-off point and associating factors for predicting cerebrovascular stenosis in asymptomatic patients with type 2 diabetes. Type 2 diabetic patients without past stroke history were enrolled between January 2011 and February 2013. We measured CCA-IMT and other risk factors of atherosclerosis. Cerebrovascular stenosis was evaluated by magnetic resonance angiography (MRA) for patients with carotid artery thickness. Carotid artery thickness was defi ned as CCA-IMT ≥0.9 mm or the presence of plaque (i.e. focal CCA-IMT ≥1.5 mm). Among 65 subjects, 47(72%) showed cerebrovascular stenosis on MRA. Maximun CCA-IMT(max-IMT) was 1.8 ± 0.5 mm in subjects with no cerebrovascular stenosis, 2.5 ± 0.8 mm in subjects with cerebrovascular stenosis(p< 0.0001). The apolipoprotein B/A-I (Apo B/A-I) ratio was 0.5 ± 0.1 in subjects with no cerebrovascular stenosis, 0.7 ± 0.0 mm in subjects with stenosis after adjusting atherosclerosis risk factors like age, sex, hypertension and smoking(p < 0.024). The area under the curves (AUC) for max-IMT was 0.782(95%CI 0.661-0.875; p<0.0001) and for Apo B/A-I ratio was 0.712(0.578-0.823; p=0027) by ROC curve analysis. The cutoff value for the greatest sensitivity and specifi city for max-IMT was 2.12 mm (sensitivity 65.2, specifi city 83.3). We suggest the carotid artery plaque and Apo B/A-I ratio might be independent predictors of cerebrovascular stenosis in asymptomatic patients with type 2 diabetes.

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A114 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

436-P 438-P Additive Relationship between Serum Fibroblast Growth Factor 21 Distribution of New ACC/AHA Statin Therapy Groups in the U.S. Level and Coronary Artery Disease Adult Population by Diabetes Status YUN SHEN, XIAOJING MA, JIAN ZHOU, XIAOPING PAN, YAPING HAO, MI ZHOU, GIUSEPPINA IMPERATORE, BARBARA BARDENHEIER, EDWARD GREGG, LINDA YUQIAN BAO, WEIPING JIA, Shanghai, China GEISS, Atlanta, GA The circulating fi broblast growth factor (FGF) 21 is primarily synthesized This study estimates the proportion of U.S. adults with or at risk of diabetes by the liver, but plays an important systemic role in regulating glucolipid (DM) eligible for statin treatment based on the 2013 American College of

metabolism and insulin sensitivity with its expression and activity associated Cardiology (ACC) and the American Heart Association (AHA) recommendations POSTERS with development of several metabolic disorders. This study was designed for cholesterol treatment to prevent atherosclerotic cardio vascular diseases Complications to investigate whether serum FGF21 level was also associated with the (ASCVD). Acute and Chronic metabolic syndrome-related cardiovascular disease, atherosclerosis, and We include 6,416 non-pregnant adults aged >20 years from the 2005-2010 its clinical features in a Chinese cohort. A total of 253 subjects aged 38-86 National Health and Nutrition Examination Survey, a probability sample of the years old visiting the Cardiology Department (Shanghai JiaoTong University civilian, non-institutionalized, U.S. population. DM status was categorized affi liated Sixth People’s Hospital) were examined by coronary arteriography as: diagnosed DM (self-reported physician diagnosis), undiagnosed DM to diagnose coronary artery disease (CAD) and hepatic ultrasonography (glycated hemoglobin [A1c] ≥6.5% or fasting plasma glucose [FPG] ≥126mg/ to diagnose non-alcoholic fatty liver disease (NAFLD). Serum FGF21 level dl), pre-DM (A1c 5.7 – < 6.5% or FPG 100 – <126 mg/dL), and normal glucose was measured by enzyme-linked immunosorbent assay and analyzed for levels (A1c < 5.7% and FPG <100 mg/dL). correlation to subject and clinical characteristics. The independent factors Table summarizes the distribution of the statin treatment group by DM of CAD were determined by multivariate logistic regression analysis. We status. 83% of adults with diagnosed DM and 77% with undiagnosed DM found that subjects with NAFLD showed signifi cantly higher serum FGF21 are eligible for statin therapy. This corresponds to 18.9 million adults. In than those without NAFLD (388.0 pg/mL (253.0-655.4) vs. 273.3 pg/mL people with pre-DM, 34% (24.7 million) meet the criteria for statin therapy. (164.9-383.7), P < 0.01). Subjects with CAD showed signifi cantly higher Of the adults with normal glucose levels, 13% (14 million) are eligible for serum FGF21, regardless of NAFLD diagnosis (P < 0.05). Trend analysis statin treatment. showed that serum FGF21 level signifi cantly elevated with the increasing For the primary and secondary prevention of ASCVD the new guidelines number of metabolic disorders (P for trend < 0.01). After adjustment of age, recommend statin treatment for the majority of adults with DM and over sex, and BMI, partial correlation analysis showed that FGF21 was positively a third with pre-DM. Their implementation together with lifestyle change correlated with total cholesterol (P < 0.05) and triglyceride (P < 0.01). In a programs should be a public health priority. logistic regression model, FGF21 was identifi ed as an independent factor of CAD (odds ratio = 2.984, 95% confi dence interval: 1.014-8.786, P < 0.05). 2013 ACC/AHA for High or Moderate Diagnosed Undiagnosed Pre-DM Normal Glu- So we concluded that increased level of serum FGF21 is associated with Intensity Statin Treatment Groups DM DM, %, SE cose % (SE) %, SE %, SE NAFLD, metabolic disorders and CAD. Supported By: National Basic Research Program of China (2012CB524906) Clinical ASCVD 32.1 (2.1) 23.7 (3.7) 12.0 (0.8) 5.1 (0.4) LDL > 190 mg/dL 1.4 (0.5) 3.3 (1.3) 3.2 (0.4) 2.4 (0.4) 437-P DM, age 40-75 yrs, LDL 70-189 49.3 (2.2) 50.4 (3.4) N/A N/A Serum Levels of Fibroblast Growth Factor 19 Are Inversely Asso- No DM or ASCVD, 40-75 yrs, LDL 70-189 N/A N/A 19.1 (1.0) 5.8 (0.4) ciated with Coronary Artery Disease in Chinese Individuals and 10-yr risk >7.5% YAPING HAO, JIAN ZHOU, MI ZHOU, XIAOJING MA, ZHIGANG LU, MEIFANG Do not meet criteria for statin treatment 17.2 (1.6) 22.6 (2.9) 65.7 (1.2) 86.7 (0.6) GAO, XIAOPING PAN, JUNLING TANG, YUQIAN BAO, WEIPING JIA, Shanghai, China The fi broblast growth factor 19 (FGF19) has been implicated as a potential 439-P regulator of glucolipid metabolism which may lead to atherosclerosis. We Effects of Active and Passive Smoking on Development of Cardio- aimed to investigated the association of FGF19 with the presence and vascular Disease with Carotid Intima-Media Thickness Examination severity of coronary artery disease (CAD) in a Chinese population. in Patients with Type 2 Diabetes Mellitus A total of 315 consecutive in-patients (including 205 men and 110 CHENG HU, FEI JIANG, YUQIAN BAO, WEIPING JIA, Shanghai, China postmenopausal women) aged 38-86 years who underwent the coronary Background: Carotid intima-media thickness (CIMT) has been widely used angiography by the standard Judkins technique were enrolled. CAD severity as a surrogate endpoint for cardiovascular disease, myocardial infarction was determined by the Gensini score. Serum FGF19 was measured by and stroke. This study was to assess the effects of active and passive quantitative sandwich ELISA. smoking exposures on the development of cardiovascular disease (CVD) in We found that FGF19 levels were not signifi cantly different between men patients with type 2 diabetes mellitus (T2DM). and women (P=0.773). Coronary angiography revealed CAD in 228 of the Methods: Seven hundred and twenty-two patients with type 2 diabetes study participants. The CAD patients were characterized as predominately were recruited in the study. A standardized questionnaire on smoking status, male, and had higher age, 2h postprandial plasma glucose (2hPG), proportion pack-years of smoking and number years of smoking cessation was given to of statins use and anti-diabetic drugs, but signifi cantly lower levels of TC the patients for their responses which were then collected for analysis. CIMT, and HDL-c (P<0.05). In addition, CAD patients had lower FGF19 levels than carotid plaque, and the internal diameter of the common carotid artery (CCA- those without CAD (128.20 [80.62-226.58] vs. 188.00 [105.10-284.70] pg/mL, diameter) were determined by High-Resolution B-mode Ultrasonography. P=0.007). FGF19 was negatively correlated with 2hPG (r= -0.150, P=0.008), Results: In comparison with non-smokers, a higher risk of CVD was found fasting insulin (r= -0.169, P=0.004), HOMA-IR (r= -0.171, P=0.004), and the in passive female smokers (OR=3.50, 95% CI 1.29~9.49, P=0.025) who also Gensini score (r= -0.141, P=0.012), but positively correlated with high-density had a signifi cantly greater CIMT value (P=0.007), CCA-diameter (P=0.041) lipoprotein cholesterol (r=0.116, P=0.041) and adiponectin (r=0.128, P=0.024). and risk of carotid plaque (OR=1.81, 95% CI 1.10~2.97, P=0.018). And both Moreover, FGF19 was found to be independently correlated with 2hPG (β= active and passive male smokers had a signifi cantly greater CIMT than -0.146, P=0.022) and adiponectin (β=0.154, P=0.016). After adjusting for non-smokers (P=0.007 and 0.004, respectively). Male active smokers had traditional risk factors, FGF19 was demonstrated to be an independent a signifi cantly higher risk of carotid plaque (OR=2.09, 95% CI 1.19~3.65, factor for Gensini score (β= -0.140, P=0.019) and the presence of CAD (β= P=0.009). -1.248, P=0.036). Conclusions: Cumulative active and passive smoking exposures to the Our study suggested that serum FGF19 was associated with the presence patients are signifi cant risk factors for carotid atherosclerosis in T2DM. Our and severity of CAD in a Chinese population. results may highlight an importance in endorsing a smoke-free environment Supported By: National Basic Research Program of China (2013CB530606) for the patients with T2DM.

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A115 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

440-P Alleviation of Oxidative Damage in the Liver of Diabetic Rats by a Garcinia kola Bifl avonoid Complex (Kolaviron) OMOLOLA R. AYEPOLA, NICOLE BROOKS, OLUWAFEMI OGUNTIBEJU, Cape Town, South Africa The liver plays an important role in the regulation of blood glucose and is a target organ of hyperglycemia. Hyperglycemia plays a crucial role in the onset

POSTERS of various liver diseases and may culminate into hepatopathy if untreated.

Complications We evaluated the protective effects of kolaviron- a bifl avonoid complex, on Acute and Chronic hepatic antioxidants, lipid peroxidation and apoptosis in the liver of diabetic rats. To induce type I diabetes, rats were injected with streptozotocin intraperitoneally at a single dose of 50 mg/kg. Oral treatment of diabetic rats with kolaviron (100 mg/kg) started on the 6th day after diabetes induction and Supported By: ADA (1-10-JF-50); NHLBI (R01HL61753, HL79611, HL113029) continued for 6 weeks (5 times weekly). Diabetic rats exhibited a signifi cant increase in the peroxidation of hepatic lipids as observed from the elevated 442-P level of malondialdehyde (MDA) estimated by High-Performance Liquid Effect of Three Insulin Analogue Regimens on Carotid Intima-Media Chromatography. In addition, Oxygen Radical Absorbance Capacity (ORAC), Thickness in Patients with Type 2 Diabetes—The Randomized total glutathione level and catalase (CAT) activity was decreased in the liver Copen hagen Insulin and Metformin Therapy (CIMT) Trial of diabetic rats. Tunnel assay revealed increased apoptotic cell death in the LOUISE LUNDBY-CHRISTENSEN, THOMAS ALMDAL, LISE TARNOW, NIELS liver of diabetic rats. Kolaviron signifi cantly attenuated lipid peroxidation WIINBERG, HENRIK VESTERGAARD, BIRGER THORSTEINSSON, OLE SNORGAARD, and apoptosis in the liver of diabetic rats, restored total glutathione levels BIRTHE GADE-RASMUSSEN, LEIF BREUM, ELISABETH R. MATHIESEN, TONNY and CAT activity. The ORAC of kolaviron-treated diabetic liver was restored JENSEN, BIANCA HEMMINGSEN, TRINE WELLØV BOESGAARD, SØREN to near-normal values. Kolaviron protects the liver against oxidative damage SØGAARD LUND, HANS PERRILD, CHRISTOFFER HEDETOFT, MICHAEL RØDER, induced by hyperglycemia. THURE KRARUP, SIMONE BJERREGAARD SNEPPEN, ELSEBETH DUUN, OLUF B. PEDER SEN, BENDIX CARSTENSEN, CHRISTIAN GLUUD, JØRN WETTERSLEV, ALLAN A. VAAG, STEN MADSBAD, Hvidovre, Denmark, Gentofte, Denmark, Hillerød, Denmark, Frederiksberg , Denmark, Copenhagen, Denmark, Køge, Denmark, Ingel- heim, Germany Insulin analogue regimens targeting fasting and/or post prandial plasma glucose excursions in patients with type 2 diabetes (T2D) may differentially infl uence the risk of cardiovascular disease (CVD). The CIMT Trial is a randomized, 3 x 2 factorial, treat-to-target (HbA1c ≤ 7.0%) multi centre trial assessing the effect of 18 month treatment with three insulin regimens in combination with metformin or placebo: insulin detemir once daily (n=137), insulin aspart biphasic one-three times daily (n=137) or a combination of insulin aspart three times daily and insulin detemir once daily (n=138) on Supported By: Cape Peninsula University of Technology; South African carotid intima-media thickness (IMT) in patients with T2D. Intention-to-treat National Research Foundation analyses were performed adjusting for stratifi cation variables. 46% of the estimated sample size was reached. Change in mean 441-P carotid IMT (results presented as mean (95%CI)) did not differ signifi cantly Reduced Insulin Sensitivity Predicts Vascular Complications in between the detemir (-0.012 mm (-0.025;0.000)), aspart biphasic (-0.009 Type 1 Diabetes mm (-0.022;0.004)) or aspart+detemir groups (0.000 mm (-0.013;0.013)). PETTER BJORNSTAD, DAVID M. MAAHS, RICHARD J. JOHNSON, MARIAN J. HbA1c was more reduced (p<0.001) in the aspart biphasic group (-1.0% REWERS, JANET K. SNELL-BERGEON, Aurora, CO (-1.2;-0.8)) compared with the detemir (-0.3% (-0.4:-0.1)) and aspart+detemir Reduced insulin sensitivity (IS) is well documented in type 1 diabetes (T1D) groups (-0.4% (-0.6;-0.3)). End-of-trial insulin dose was higher (p<0.001) in and may contribute to vascular complications. We examined reduced IS as the detemir group (1.6 IU/kg/d (1.4;1.8)) compared with the aspart biphasic a risk factor for macro- and microvascular complications in the prospective (1.0 IU/kg/day (0.9;1.1) and aspart+detemir groups (1.1 IU/kg/day (1.0;1.3)). CACTI study. Weight gain was higher (p<0.01) in the aspart biphasic (3.3 kg (2.7;4.0)) and Participants (N=652) were 19-56 yrs old at baseline and re-examined 6 the aspart+detemir groups (3.2kg (2.6;3.9)) compared with the detemir group yrs later. Urinary albumin excretion was measured, and categorized as (1.9kg (1.3;2.6)). The number of patients with serious adverse events or microalbuminuria or greater. Rapid GFR decline was defi ned as loss >3mL/ severe hypoglycemia did not differ between groups. min/1.73m2/yr by CKD-EPI cystatin C. Diabetic retinopathy (DR) was based Despite differentiated effects on HbA1c, insulin dose and weight, no on self-reported history and proliferative DR (PDR) as history of laser eye differences in carotid IMT was found. Larger and longer randomized trials therapy. Coronary artery calcium (CAC) was measured using electron beam assessing effects of different insulin analogue regimens on CVD in patients computed tomography. Progression of CAC was defi ned as a change in the with T2D are needed. square root transformed CAC volume ≥2.5. IS was estimated by insulin Supported By: Novo Nordisk A/S sensitivity index (ISI), an equation derived from clamp studies. Predictors of each complication were examined in stepwise logistic regression with 443-P subjects with complications at baseline excluded. Age, T1D duration, sex, Type 2 Diabetes and Obstructive Sleep Apnea Synergistically Affect HbA1c, SBP, LDL-c, and ISI were considered for inclusion. Endothelial Function Reduced ISI independently predicted development of albuminuria DIMITRIOS BALTZIS, JESSIE P. BAKKER, MICHAEL AUSTER, ANA TELLECHEA, (p=0.005), rapid GFR decline (p=0.02), DR (p=0.02), PDR (p<0.05) and CACp IOANNA ELEFTHERIADOU, YANA OSTROVSKY, ATUL MALHOTRA, SANJAY R. (p<0.0001) in separate multivariable stepwise models (Figure 1). PATEL, ARISTIDIS VEVES, Boston, MA, San Diego, CA IS is an independent, common risk factor for the development of vascular The interaction between obstructive sleep apnea (OSA) and T2DM regarding complications of T1D and a potential therapeutic target. vascular reactivity is not known. We enrolled 4 groups: healthy controls, subjects with T2DM, OSA, and both DM+OSA. Macrovascular function was measured by fl ow-mediated dilation (FMD; endothelium-dependent) and nitroglycerin-induced dilation (NID; endothelium-independent) at the brachial artery. Microvascular function was assessed by LASER Doppler fl owmetry before and after iontophoresis of acetylcholine (endothelium-dependent) and sodium nitroprusside (endothelium-independent) at the forearm. All participants underwent a home-based cardiorespiratory sleep study and the apnea-hypopnea index (AHI) was used to classify patients into OSA (AHI ≥10 events/hour) and non-OSA groups. DM+OSA subjects had lower FMD than

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A116 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES the other groups, with no difference in NID across groups (Table 1). A similar the 6-year cohort. Bootstrap procedure and Harrell’s concordance (C) index trend towards lower endothelium-dependent microvascular reactivity was was used for internal validation and receiver operating characteristic (ROC) evident. There were no differences in serum epinephrine, norepinephrine, curves was for evaluating the predictability of 6-year CVD events of each cortisol, lipids and CRP. In forearm skin biopsies, no differences were equation. detected in the number of infl ammatory cells and blood vessels in the We excluded subjects with previous history of CVD or insuffi cient clinical dermis, but, when compared directly to DM+OSA, OSA subjects tended to data to calculate the CVD risk equation for the analysis. Their mean age have increased infl ammatory cells [64 (43-67) vs. 35 (31-45) cells/visual fi eld, was 60 ± 10 years, mean duration of diabetes was 10 ± 7 years and median p=0.063]. We conclude that OSA and DM exert a synergistic detrimental follow-up period was 6.3 years. For entire study population, family history POSTERS effect on endothelial function. of CVD, albuminuria, age, body mass index (BMI), blood pressure, HDL Complications Table 1. Data are Shown as n, Mean ± SD or Median (Interquartile Range). cholesterol, duration of diabetes and HbA1c were selected for the equation Acute and Chronic (C-index = 0.702, P for fi t = 0.675). For men, although the equation included Controls DM OSA DM and OSA P similar variables in the case of entire population, it showed a higher C-index n2423910 (C-index = 0.829, P for fi t = 0.991). By contrast, for women, the equation Age(years) 43 ± 14 49 ± 7 48 ± 8 52 ± 6 NS included age, duration of diabetes and BMI (C-index = 0.654, P for fi t = AHI (events/hour) 3 (1-5) a 5 (2-7) a 27 (14-38) b 18 (13-29) b a vs. b 0.672). Area under curve of ROC curve for prediction of 6-year CVD events <0.001 was 0.844 [95% confi dence interval (CI), 0.748 - 0.940] in men and 0.659 (0.555 - 0763) in women, which were somewhat superior comparing those FMD (%) 8.4 ± 2.7c 9.2 ± 2.9 c 9.2 ± 2.2 c 5.5 ± 1.8 d c vs. d <0.02 of UKPDS risk engine in both sex: 0.744 (0.616 - 0.872) in men and 0.530 NID (%) 20.2 ± 5.3 19.8 ± 5.3 20.4 ± 3.4 15.2 ± 4.6 NS (0.416 - 0.645) in women. Acetylcholine (%) 30.7 (16.9-65.3) 25.4 (11.8-46.3) 52.6 (14.2-75.8) 16.4 (11.5-42.4) NS In conclusion, we successfully developed the equation for predicting Nitroprusside (%) 32.7 (13.2-47.9) 31.2 (7.5-48.6) 20.3 (11.3-77.4) 22.3 (49.6-46.9) NS CVD risk fi tting for Korean T2DM patients. It might be useful to guide for managing CVD risk factors and screening CVD in Korean T2DM patients Supported By: 1R01HL110350 especially for men.

444-P 446-P Therapeutic Use of Oxytocin on the RAGE Complex in Cardiovascular Vaspin Inhibits Cytokine-induced Nuclear Factor-kappa B Activa- and Renal Complications of Type 1 and 2 Diabetes tion and Adhesion Molecule Expression via AMP-activated Protein DENIS YIP, ERIC PLANTE, BOGDAN DANALACHE, MAREK JANKOWSKI, JOLANTA Kinase Activation in Vascular Endothelial Cells GUTKOWSKA, AHMED MENAOUAR, Montreal, QC, Canada CHANG HEE JUNG, MIN JUNG LEE, YU MI KANG, KEE-HO SONG, SUNG RAE Diabetes mellitus (DM) is one of the leading causes of death worldwide KIM, SUNG WOO PARK, JOONG-YEOL PARK, Seoul, Republic of Korea, Bucheon, with its cardiovascular and renal complications contributing to mortality. A Republic of Korea physiological change attributed to DM is the formation of advanced glycation Vaspin is an adipocytokine that was recently identifi ed in the visceral endproducts (AGEs). Activation by ligand binding to the corresponding AGE adipose tissue of diabetic rats and has anti-diabetic and anti-atherogenic receptor (RAGE) has been linked to the onset and prolongation of pro- effects. We hypothesized that vaspin prevents infl ammatory cytokine- infl ammatory responses that may worsen diabetic symptoms. Oxytocin (OT), induced nuclear factor-kappa B activation by activating AMP-activated a peptide often used to induce parturition, has shown cardioprotective and protein kinase (AMPK) in vascular endothelial cells. anti-infl ammatory effects. We hypothesize that activation of the G-protein We examined the effects of vaspin on NF-kappa B activation and the coupled OT receptor, can lead to cleavage of RAGE thus dampening the expression of the NF-κB-mediated genes intercellular adhesion molecule-1 infl ammation seen in DM. (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), E-selectin, and Experiments were performed in animal models of type I and II DM and in monocyte chemoattractant protein-1 (MCP-1). Human aortic endothelial vitro in H9c2 embryonic rat cardiac myoblasts. 4 week old Wistar rats were cells (HAECs) were used. Tumor necrosis factor alpha (TNF alpha) was used treated with streptozotocin (STZ) to induce DM type I, followed by OT (125 as a representative proinfl ammatory cytokine. ng/kg/h) for 6 weeks. Similarly, 4 week old db/db, leptin receptor defi cient Treatment with vaspin signifi cantly increased the phosphorylation of model of DM type II, were treated with OT (125 ng/kg/h) for 12 weeks. Heart, AMPK and acetyl-CoA carboxylase, the down-stream target of AMPK. aorta and kidney samples from each group were stained with periodic acid Furthermore, treatment with vaspin signifi cantly decreased TNF alpha- Schiff and picrosirius red for glycogen and collagen respectively. Western induced activation of NF-kappa B, as well as the expression of the adhesion blot and immunostaining analysis was performed on ventricular and kidney molecules ICAM-1, VCAM-1, E-selectin, and MCP-1. These effects were samples. abolished following transfection of AMPK alpha1-specifi c small interfering We observed diminished glycemia as well as reductions in glycogen RNA. In an adhesion assay using THP-1 cells, vaspin reduced TNF alpha- deposits in the aorta, kidney and heart in both models of DM when treated induced adhesion of monocytes to HAECS in an AMPK-dependent manner. with OT. Stained aortas had profound collagen deposits in STZ rats which Vaspin might attenuate the cytokine-induced expression of adhesion decreased with OT treatment. RAGE content was lessened in the left molecule genes by inhibiting NF-kappa B following AMPK activation. ventricle of the OT treated STZ rats versus those receiving vehicle. OT Supported By: NRF (2013R1A1A1004798) treatment of diabetic animals resulted in a decrease of oxidative stress accumulation in the sections of the heart and kidney. These results indicate that treatment with OT reduces diabetic parameters 447-P such as blood glucose and insulin resistance. It has potential in reducing Rage Activation Reduces Cardiomyocyte Mitochondrial Function in organ damage by DM in the heart, kidney and aorta. Its use as a therapeutic a Ceramide-dependent Manner should be further explored. MICHAEL NELSON, TREVOR TIPPETTS, DUANE WINDEN, PAUL REYNOLDS, Supported By: CIHR BENJAMIN T. BIKMAN, Provo, UT Type 2 diabetes mellitus is associated with a dramatic increase in the risk of multiple cardiovascular complications, including heart failure. The role of 445-P advanced glycation endproducts (AGE) is already an established cause of A 6-Year Cohort-based Development of Cardiovascular Disease Risk diabetic cardiomyopathy. Given the role of AGE and its receptor, RAGE, in Prediction Model Fitting for Korean Patients with Type 2 Diabetes activating infl ammatory pathways, which increases ceramide biosynthesis, and Its Validation we sought to determine the role of ceramides as a mediator of RAGE- BOKYUNG KOO, SOHEE OH, YOON JI KIM, KYONGYEUN JUNG, EUN ROH, induced altered heart mitochondrial function. Using an in vitro model, we CHANG HO AHN, MIN KYEONG KIM, EU-JEONG KU, MIN KYONG MOON, Seoul, treated H9C2 cardiomyocytes with the AGE carboxymethyl lysine (CML-BSA), Republic of Korea followed by permeabilization and mitochondrial respiration assessment. The aim of this study was to develop the equation for cardiovascular We found that mitochondrial respiration was signifi cantly reduced in AGE- disease (CVD) risk assessment fi tting for Korean patient with type 2 diabetes treated cardiomyocytes, but not when co-treated with myriocin, a ceramide mellitus (T2DM) and compare its performance with UK Prospective Diabetes inhibitor. Moreover, we exposed WT and RAGE KO to a brief period of cigarette Study (UKPDS) risk engine. smoke exposure, which increases heart ceramide accrual and found reduced The multivariable equation for predicting CVD events was developed mitochondrial respiration in left ventricle myocardium from WT mice, but the using the Cox proportional hazard model with the stepwise selection in RAGE KO mice were protected from this effect. Altogether, these fi ndings

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suggest a RAGE-ceramide axis as an important mediator of cardiomyopathy. 450-P The Ratio of TG to HDLc Predicts Incident Albuminuria and Pro- 448-P gression of Coronary Artery Calcifi cation in Type 1 Diabetes Pulse Wave Velocity, Augmentation Index, and Flow-mediated PETTER BJORNSTAD, DAVID M. MAAHS, MARIAN J. REWERS, JANET K. SNELL- Dilation Provide Distinct Measures of Conduit Artery Function BERGEON, Aurora, CO NAGASHREE GUNDU RAO, LINDA JAHN, LEE M. HARTLINE, SHARMILA C. Coronary artery disease and nephropathy are the most common causes SUBARAN, BRENT J. LOGAN, ZHENQI LIU, EUGENE J. BARRETT, Charlottesville, of mortality in type 1 diabetes (T1D). ABC goals (A1c<7.0%, BP<130/80

POSTERS VA mmHg, LDLc<100mg/dL) lowers but does not abolish the risk of cardiorenal Complications Pulse Wave Velocity (PWV), Augmentation Index (AI) and Flow-Mediated complications. Incident albuminuria and progression of coronary artery Acute and Chronic Dilation (FMD), each measure conduit artery function, and each have calcifi cation (CACp) mark preclinical cardiorenal disease. We explored their been shown to predict cardiovascular disease (CVD) risk independently relationships with several lipid markers. of traditional CVD risk factors. Whether these measures provide similar Subjects (N=652) were 19-56 yrs old at baseline and reexamined 6 or distinct information regarding conduit vessel health is not known. We yrs later. Urinary albumin excretion was measured, and categorized as compared these three measures of conduit artery function in 134 studies microalbuminuria (MA) or greater. CACp, measured using electron beam CT, in healthy subjects and 53 studies in subjects with metabolic syndrome was defi ned as a change in the square root transformed CAC volume ≥2.5. (age 13-59, BMI 17.2-49). PWV and AI, which refl ect arterial stiffness, were The association of LDLc, apoB, nonHDLc and TG:HDLc ratio with CACp and measured by tonometry, while FMD, which is a measure of nitric-oxide incident albuminuria were examined in logistic regression; subjects with mediated vascular reactivity, was measured by ultrasound. In addition, MA at baseline were excluded. The models were adjusted for age, sex, vascular measurements were repeated following a 1mU/kg/min euglycemic T1D duration, A1c, SBP, DBP, and BP meds. C-statistics and IDI were used to insulin clamp x 120 min, to assess insulin-mediated changes in PWV, AI and assess prediction performance. FMD in healthy subjects. TG:HDLc ratio independently predicted incident albuminuria (p=0.01) and Results: At baseline, PWV correlated signifi cantly but weakly with AI CACp (p=0.002), while LDLc, ApoB and nonHDLc did not (Figure 1). TG:HDLc ratio also improved the AUC (p=0.003) and discrimination slope (p=0.009) of (rsp=0.37, P<0.001), while % change in FMD did not correlate with either a model with A1c, BP and TG:HDLc in place of LDLc predicting CACp. PWV (rsp=-0.09, P=0.40), or with AI (rsp=-0.17, P=0.09). Hyperinsulinemia tended to decrease AI (baseline 5.8 + 2.4, after insulin 2.8 + 2.7; P=0.05) and TG:HDLc ratio appears to be superior to LDLc, apoB and nonHDLc in enhance % change in FMD (baseline 6.8 + 1.2%, after insulin 9.8 + 1.2%; predicting incident albuminuria and CACp in T1D. P=0.05), while PWV (baseline 5.44 + 0.2, after insulin 5.46 + 0.2; P=0.45) did not change. Multi-variate correlation analyses revealed that HR-adjusted AI and PWV were independently associated with age (rsp=0.35, P<0.001; rsp=0.31, P=0.002), and BP (rsp=0.22, P=0.02; rsp=0.21, P=0.04). Height negatively correlated with both AI (rsp=-0.3, P=0.001) and PWV (rsp=-0.26, P=0.01). % change in FMD was independently associated only with HR (rsp=0.36, P=0.02). Thus, AI, PWV and FMD were inhomogeneous at baseline, in their response to insulin and their co-variates. We conclude that AI, PWV and FMD provide distinct measures of vascular health and cannot be used interchangeably as measures of conduit artery function.

449-P Supported By: ADA (1-10-JF-50); NHLBI (R01HL61753, HL79611, HL113029) Therapeutic Intensifi cation Strategy and Incident Cardiovascular Disease (CVD) in Type 2 Diabetes Mellitus (T2DM) 451-P MARY T. KORYTKOWSKI, MARIA M. BROOKS, TREVOR J. ORCHARD, DILHARI The Effect of Sex Hormones to Coronary Artery Disease via Insulin DEALMEIDA, MANUEL LOMBARDERO, JUSTIN KANTER, LINDA M. SIMINERIO, Sensitivity Pittsburgh, PA JUNG HWAN PARK, SANG MO HONG, CHANG BEOM LEE, YONG SOO PARK, More attention is being paid to cardiovascular (CV) safety of T2DM DONG SUN KIM, YOU HERN AHN, WOONG HWAN CHOI, Seoul, Republic of medications. Studies using data from electronic medical records (EMR) Korea have potential to provide safety information in diverse patient populations The metabolic syndrome represents a constellation of lipid and nonlipid beyond those recruited for randomized controlled clinical trials. risk factors of metabolic origin and closely linked to a generalized metabolic To investigate the CV safety of therapeutic intensifi cation with insulin disorder called insulin resistance. Higher testosterone levels in aging males (INS), glucagon-like-peptide analogs (GLP-1), or a different oral diabetes are independently associated with higher insulin sensitivity and reduced risk medication (ODM) class in patients with uncontrolled T2DM (A1C≥7%) on of metabolic syndrome (MS). We investigate sex hormones effect to insulin 1-2 ODM, a health system EMR was used to identify incident CVD events resistance syndrome and coronary artery disease (CAD) in aging male. We are using ICD9 codes for CAD, CBVD, and other CVD (CHF, PVD, arrhythmia) for to know the difference of endogenous testosterone, estradiol (E2), and the 4y following intensifi cation. Patients with baseline CVD required new ICD-9- ratio of estradiol to testosterone (E/T) according to the presence or absence CM codes to defi ne incident events. of CAD. We studied to investigate the relation of endogenous testosterone, Baseline CV disease (CVD) was more prevalent in INS (n=372) than GLP1 E2, E/T with metabolic syndrome and individual risk factor. We analyzed (n=59) or ODM (n=833) groups (65 vs. 39 vs. 54%, p<0.001). This group was 211 male patients who had undergone coronary angiography at cardiology older (61±14 vs. 57±12 vs. 63±13 yrs, p<0.001) with higher baseline A1C department in Hanyang university hospital. We excluded signifi cant (9.2±2.0 vs. 8.3± 1.2 vs. 8.2±1.3%, p<0.001). There were no group differences weight loss(≥10%), acute and chronic infection, hepatorenal dysfunction, in age and BMI adjusted reductions in A1C following intensifi cation. steroid medication and heavy alcoholics. The tests of anthropometric Signifi cant group differences for incident CVD were observed with Kaplan- measurement were body mass index (BMI) and waist circumference. Meier estimates of 58%, 31%, and 52% (log rank p=0.002), due largely to Hormonal determinations were total testosterone, E2, and E/T. Among other CVD. Using multivariable Cox regression models adjusting for baseline other cardiovascular risk factors, MS is most important contributors to CAD. differences in age, sex, race, BMI, A1C, creatinine, and baseline CVD, Even after adjustment for age, BMI, smoking, alcohol consumption, higher Hazard Ratios for incident CVD were 1.23 (CI: 0.96-1.57) for INS vs. ODM and testosterone is associated with higher insulin sensitivity. Each standard 0.49 (0.26-0.92) for GLP-1 vs. ODM (p=0.03). Similar trends were noted for deviation (1.88 ng/mL) increase in total testosterone was associated with analyses limited to patients free of CVD (n=670) at baseline (p=0.07). 51% reduced risk of having MS (OR=0.49: 95% CI, 0.36-0.68). Although men Recognizing the small numbers of patients receiving GLP-1 and no with CAD tend to have lower testosterone levels, there was no statistical information regarding T2DM duration, there was no increase in CVD risk signifi cance. Higher testosterone levels might have a protective role in the with GLP1 therapy. Incident CVD occurred with similar frequency following development of MS and possibly CAD through the improvement of insulin intensifi cation with INS or ODM. sensitivity. Supported By: Sanofi

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452-P that would raise troponin. Patients with diagnosis of acute coronary Associations of Omentin Levels with Visceral Adiposity Index and syndrome (ACS) or who met the American College of Cardiology/European Vascular Complications in Patients with Type 2 Diabetes Society of Cardiology (ACC/ESC) defi nition for myocardial infarction were CHAN-HEE JUNG, KYU-JIN KIM, BO-YEON KIM, CHUL-HEE KIM, SUNG-KOO excluded, as well as those with other known causes of troponin elevation KANG, JI-OH MOK, Bucheon, Republic of Korea (pulmonary embolism, sepsis, myocarditis, pericarditis, tachyarrhythmia, Omentin is a adipokine, whose expression is abundan tl y de t e c t e d in v is c er al hypotension, stroke, recent cardiac surgery, cocaine abuse and chronic fat tissue and low levels of omentin are associated with insulin resistance renal failure) were excluded. Included Patients were divided into 2 groups. Group 1: DKA without elevated troponin (<0.04 ng/dl) and Group 2: DKA with and endothelial dysfunction. Visceral adiposity index (VAI) is a recently POSTERS proposed marker of both visceral fat distribution and dysfunction. Until elevated troponin (>=0.04 ng/dl). Groups were then compared for baseline Complications now, there is no published study to investigate the associations of omentin variables and 2 year major adverse coronary event (MACE) rates. Out of Acute and Chronic with VAI, vascular complications in T2DM. Therefore, we investigated 620 patients, 176 met inclusion criteria; 130 in Group 1 and 46 in Group 2. the relationships between omentin, VAI, carotid atherosclerosis, diabetic Patients in Group 1 had a total of 4 MACE (3.08 %) and group 2 had a total of retinopathy (DR) and nephropathy (DN) in T2DM patients. We recruited 160 3 MACE (6.52 %). Multivariable logistic regression did not fi nd a signifi cant patients (men 102, women 58, mean age: 57 years) who evaluated carotid association with troponin elevation and 2-year MACE events (p-value = ultrasonography, brachial-ankle pulse wave velocity (baPWV), ankle-brachial 0.304), however, given how few MACE events we found, this study was index (ABI), DN and DR. Serum omentin levels were assessed by ELISA and underpowered to see a difference between groups. Glomerular fi ltration rate VAI was calculated by the formula: (Males:[WC/(39.68+(1.88xBMI))x(TG/1.03) (GFR) at presentation was found to be inversely related with future coronary x(1.31/HDL)],Females:[WC/(36.58+(1.89xBMI) x(TG/0.81)x(1.52/HDL)]. The events in DKA patients (p value = 0.009). In this retrospective study with few mean levels of serum omentin were 499 ng/ml and the mean carotid intima- MACE events, elevated troponin in isolated DKA was not associated with media thickness (CIMT) were 0.57 mm. In correlation analysis, omentin increased risk of future MACE over patients with normal troponins; however showed negative correlation with VAI, but was not signifi cantly correlated renal insuffi ciency did seem to be predictive. Larger databases should be with CIMT, baPWV and ABI. Serum mean omentin levels were not different queried to confi rm these fi ndings. according to the presence or absence of DR or DN. The mean levels of CIMT signifi cantly increased progressively across VAI tertiles (p=0.008). The mean 455-P VAI levels were not different according to the presence or absence of DR or Implications of High-Mobility Group A1 Protein in High-Glucose- DN. This present study suggests that serum omentin is not related to CIMT induced Vascular Smooth Cells Proliferation and microvascular complications. Also, VAI is not related to microvascular LIU JIANGHUA, ZHANG QINGHAI, ZHAO ZHIBO, WU YING, ZHENG YI, CAO complications. On the other hand, VAI is correlated with CIMT in patients RENXIAN, ZHONG JING, ZU XUYU, WEN GEBO, Hengyang, China with T2DM. Future prospective studies with larger numbers of patients are High-mobility group protein A1 (HMGA1), an architectural transcription required to establish a direct relationship between serum omentin levels, factor, was found to regulate multiple genes expression in mammals. Recent VAI and vascular complications in patients with T2DM. studies fi rmly indicate an association between HMGA1 and type 2 diabetes. However, the presence and function of HMGA1 in diabetic vasculopathy has 453-P not been substantiated. Here, we fi rstly determined the HMGA1 changes in Elevation of HDL-C in Response to Statin Treatment to Be Closely aorta tissue of normal control rats (normal chaw diet), nondiabetic rats (high Related to the Regression of Carotid Atherosclerosis glucose high fat diet, HGHF-diet) and diabetic rats (HGHF-diet and injected YASUSHI ISHIGAKI, SUMINORI KONO, HIDEKI KATAGIRI, SHINICHI OIKAWA, with 30 mg/kg of streptozotocin singly) at 8 weeks. In diabetic rats, a Morioka, Japan, Fukuoka, Japan, Sendai, Japan, Tokyo, Japan higher level of blood glucose and plasma lipids, an increase of intima-media Atherosclerosis is strongly associated with increased mortality in subjects thickness, and a signifi cant up-regulation and accumulation of HMGA1 mainly with diabetes. Carotid intima-media thickness (IMT) is commonly measured in nucleus and around nuclear membrane were detected. In vitro, we found as a surrogate marker for cardiovascular risk. Statins are well-established that high-glucose(less than or equal to 22.2 mM) could increase HMGA1 protective agents against atherosclerosis and reportedly suppress IMT mRNA and protein levels and promote proliferation of cultured aortic smooth progression in subjects with diabetes. To clarify the effects of statins on muscle cells. Furthermore, luciferase reporter assays further showed that subclinical atherosclerosis, we investigated changes in carotid IMT and lipid high-glucose could enhance HMGA1 transcription activity .Moremore, cyclin profi les in a multi-center, prospective, randomized trial. D1 expression was found to be elevated by high glucose, and this process Hypercholesterolemic subjects with type 2 diabetes were randomly could be abrogated by the transfection of HMGA1 shRNA plasmid in smooth assigned to open-label treatment with either pravastatin or pitavastatin. muscle cells. Taken together, this work provides the fi rst evidences for the The primary endpoint of this study was the IMT change after 36 months of role of HMGA1 in high-glucose induced smooth muscle cells proliferation in statin treatment. early diabetic vascular disease. Thus, manipulation of HMGA1 expression in A total of 97 subjects (51 pitavastatin; 46 pravastatin) completed this vascular tissues might be a novel approach for therapeutic intervention in 36-month study. LDL-C decreased signifi cantly from 163.4±27.9 mg/dl at diabetic vascular complications. baseline to 100.4±19.6 mg/dl at 36 months in the pitavastatin group and from Supported By: NSFC (81170807) 159.7±25.6 mg/dl to 118.5±22.1 mg/dl in the pravastatin group. The mean IMT showed moderate regression in both the pitavastatin (–0.070±0.215 mm, P < 456-P 0.05) and the pravastatin (–0.067±0.260 mm) group. However, there was no Expression Levels of Monocyte GLP-1 Receptor Are Associated signifi cant difference in IMT change between the two groups. When the two with Intima-Media Thickness in Patients with Type 2 Diabetes groups were combined, the 36-week change in mean IMT was signifi cantly TAKASHI MISHIMA, KOKA MOTOYAMA, YUKO YAMAZAKI, TOMOAKI MORIOKA, associated with HDL-C change (r = –0.24, P = 0.03), but such an association KATSUHITO MORI, SHINYA FUKUMOTO, TETSUO SHOJI, MASANORI EMOTO, was not observed for other lipid parameters. MASAAKI INABA, Osaka, Japan The administration of statins for 3 years to subjects with type 2 diabetes Diabetes is a marked risk factor for cardiovascular disease. Recent resulted in a signifi cant regression of carotid IMT. Elevation of plasma studies have shown that GLP-1 receptor (GLP-1R) agonist directly inhibited HDL-C with statin treatment was closely related to regression of athero- progression of atherosclerosis. Though GLP-1R is expressed on monocyte sclerosis. which is one of key players for atherosclerosis, it is unknown whether monocyte GLP-1R levels are involved in the development of atherosclerosis. 454-P The aim of this study is to examine the association of monocyte GLP-1R Signifi cance of Elevated Troponin in Patients with Isolated Diabetic levels with carotid intima-media thickness (IMT). 201 patients with type2 Ketoacidosis (DKA): A Retrospective Study diabetes (age, 62 ± 13 (SD) years, duration 14 ± 11 (SD) years) were enrolled in NABA R. MAINALI, DEEPIKA PRADHAN SHRESTHA, ANTHONY DONATO, West this cross-sectional study. IMT of common carotid artery was measured by Reading, PA, Hershey, PA ultrasonography. Circulating monocyte GLP-1R was fl uorescently labeled and Troponin elevation in the absence of acute coronary event has been its expression levels were quantifi ed by fl ow cytometry. In simple regression reported in patients with Diabetic Ketoacidosis (DKA). Whether such analysis, the IMT was signifi cantly associated with age (r=0.263, p=0.001), troponin elevation in DKA has the same prognostic relevance as it does in body mass index (BMI) (r=-0.181, p=0.012), and monocyte GLP-1R levels (r=- acute coronary syndromes is not known. Using ICD-9 coding at discharge, 0.171, p=0.020). Multiple regression analysis including age, gender, duration, we identifi ed 620 consecutive patients admitted with DKA from 1/1/2003 - BMI, LDL cholesterol levels, HbA1c, serum creatinine, insulin resistance 10/25/2011. We included patients with DKA and no other admission diagnosis index by homeostasis model assessment ratio, monocyte number and

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A119 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

monocyte GLP-1R levels as independent variables revealed that age (β= 459-P 0.365, p=0.001), LDL cholesterol levels (β= 0.262, p=0.004), monocyte GLP- Obesity in Early Stage Looks More Important Than BMI’s Above 30 1R levels (β=- 0.170, p=0.043) were the signifi cant independent contributors Kg/m2 in Terms of Arterial Stiffness and Cardiovascular Risks to IMT. In conclusion, monocyte GLP-1R levels were associated with IMT in HAKAN SARLAK, EROL ARSLAN, SEREF DEMIRBAS, MUSTAFA CAKAR, OMER patients with type2 diabetes. This study suggests that monocyte GLP-1R KURT, MUHARREM AKHAN, SIRZAT YESILKAYA, Ankara, Turkey, Eski ehir, Turkey, expression may be involved in the development of atherosclerosis. Kars, Turkey The prevalence of obesity is rising globally. Obesity is a signifi cant

POSTERS 457-P independent predictor of cardiovascular risk and mortality. Increased Complications Independent Prognostic Value of Plasma Levels of N-terminal pro- arterial stiffness is one of the mechanisms to explain this fi nding. In this Acute and Chronic B-type Natriuretic Peptide (NT-proBNP) in Asymptomatic Diabetic study we aimed to investigate the effects of obesity and degree of BMI on Patients arterial stiffness. PAUL VALENSI, MINH TUAN NGUYEN, ISABELLE PHAM, ISABELA BANU, A total of 1054 subjects (469 females, 44.5%) were included in to the BERNARD CHANU, EMMANUEL COSSON, Bondy, France study. The mean ages of female and male subjects were 48.3±13.5 and We previously showed that NT-proBNP is a marker of coronary stenoses 42.4±16.2 years, respectively. The subjects were patients having arterial (CS) in diabetic patients without cardiac history or symptom. NT-proBNP stiffness measurements applied in the internal medicine outpatient was also shown to predict cardiac events in the diabetic population. The clinics for control reasons. The mean body mass index (BMI), pulse wave present study aimed to determine the prognostic value of NT-proBNP velocity (PWV), augmentation index (Aix) and central aortic pressure (CAP) independent from silent coronary disease and left ventricle hypertrophy measurements of the patients were 27.7±5 kg/m2; 8.5±1.8 m/sec; 22.3±16.5 (LVH) in asymptomatic diabetic patients. % and 127.4±22.6 mmHg, respectively. The BMI was signifi cantly associated We included 323 diabetic patients (17 type 1, 306 type 2) without cardiac with PWV, Aix and CAP (r=0.327, 0.422 and 0.493 respectively; p<0,001). history or symptom but with ≥1 additional risk factors. Silent myocardial Arterial stiffness was getting worse with age as expected. The effect of ischemia (SMI) was assessed using stress myocardial scintigraphy and CS BMI on arterial stiffness was stronger in patients with lower BMI’s and the using coronary angiography in those with abnormal scintigraphy. Left ventricle cutoff value was calculated as 30 kg/m2. mass was evaluated reliably by echocardiography (ASE criteria) in 282 of them, These results show that BMI values below 30 kg/m2 have stronger effects and LVH was defi ned by LV mass ≥106 (women) or 110 g/m² (men). Plasma NT- on arterial stiffness measurements compared to higher values, leading to proBNP was measured. Patients were followed during 4.6±2.6 years. the idea that obesity in early stages may be more important than late stages LVH was detected in 92 patients, SMI in 108 patients 39 of whom had CS. in terms of future cardiovascular risks. The prevalences of LVH (19.4, 35.1 and 43.2%; p<0.001) and CS (5.6, 10.2 and 20.4%; p<0.001) were higher in the highest tertiles of NT-proBNP. At follow- up 29 cardio-vascular events occurred (1 amputation, 4 stroke, 4 cardiac death, 5 heart failure, 5 revascularisations, 10 acute coronary syndrome). In multivariate analysis including SMI and CS the highest tertile of NT-proBNP (>34 pg/ml) predicted the events independently from SMI (OR 2.9 [1.4-6.0], p<0.005) and CS (OR 2.4 [1.1-5.2], p=0.02). In another model including also LVH the highest tertile of NT-proBNP was still an independent predictor (p<0.0001 and p=0.003 respectively). This study suggests that in asymptomatic diabetic patients NT-proBNP is a risk marker for cardio-vascular events independent from coronary status and LVH.

458-P In Asymptomatic Diabetic Patients a Coronary Artery Calcium Score =100 Agatston Units Is Associated with a Three-Fold Increased Risk of Silent Myocardial Ischemia PAUL VALENSI, VÉRONIQUE EDER, ISABELA BANU, MINH TUAN NGUYEN, ISABELLE PHAM, EMMANUEL COSSON, Bondy, France, Bobigny, France High coronary artery calcium (CAC) scores were shown to predict a higher likelihood of inducible myocardial ischemia and to be associated with a poor cardio-vascular prognosis. However the predictive value for coronary 460-P stenoses (CS) has not been tested in asymptomatic diabetic patients. DASH Diet and Walking Reduced Ambulatory Blood Pressure Values This study aimed to evaluate the predictive value of a high CAC score for in Patients with Type 2 Diabetes and Uncontrolled Hypertension silent myocardial ischemia (SMI) and CS in high risk asymptomatic diabetic TATIANA PEDROSO DE PAULA, LUCIANA VERÇOZA VIANA, ALESSANDRA patients. TEIXEIRA NETTO ZUCATTI, CRISTIANE BAUERMANN LEITÃO, JORGE LUIZ CAC score was measured by computed tomography in 111 diabetic GROSS, MIRELA J. AZEVEDO, Porto Alegre, Brazil patients without cardiac history or symptom, with a normal resting ECG Data on the potential benefi cial effects of combining diet and exercise and ≥1 additional risk factors. SMI was assessed using stress myocardial on blood pressure (BP) are still scarce. To evaluate the effects of lifestyle scintigraphy and/or stress echocardiography, and CS using coronary intervention on BP homeostasis, we conducted a four-week parallel angiography in those with an abnormal SMI test. randomized clinical trial in 40 patients with type 2 diabetes and hyper- CAC score was ≥100 Agatston units in 35.6% of the patients. SMI was tension using anti-hypertensive drugs and with uncontrolled BP at offi ce detected in 19 patients (17.1%). A coronary angiography was performed in 11 (≥140/90 mmHg; Omron HEM-705CP) and at ambulatory BP monitoring of SMI patients and detected signifi cant CS in two of them. CAC score was (ABPM; daytime ≥135/85 mmHg; Spacelabs 90207). Patients were randomly associated with coronary status (no SMI: median value 14 (range 0-2900); assigned to the Intervention Group [DASH diet plus walking 15-20 min SMI without CS: 146 (23-3230) and SMI with CS: 1671 (364-2978) (p<0.01)), daily, using a pedometer (Digiwalker CW200), additionally to their baseline and similarly for a CAC score ≥100 (in 29/33 patients without SMI (31.2%), activity] or Control Group (ADA dietary guidelines without any physical 6/9 with SMI and no CS (66.7%) and 2/2 patients with SMI and CS; p<0.05). activity recommendation). Baseline characteristics did not differ between A CAC score ≥100 predicted the presence of SMI: 27.5% of patients had Intervention and Control groups. Changes in offi ce BP did not differ between SMI vs. 11.3% of those with CAC <100 (odds ratio 3.0 [1.1-8.2], p<0.05), with groups. ABPM during the study are shown in the Table. The reduction of a sensitivity and specifi city of 58% and 68%, and positive and negative 24-h and night-time systolic ABPM was greater in Intervention than in predictive values of 27 and 89%, respectively. Control group. Daytime ABPM was reduced only in Intervention group. The These data suggest that in asymptomatic high risk diabetic patients CAC number of steps and 24-h urine aldosterone and potassium increased and score is associated with cardiac ischemic status, with a three-fold increased the 24-h urinary sodium decreased (P <0.05) only in the Intervention group. risk of SMI when the score is ≥100. The negative predictive value of CAC In conclusion, a DASH diet associated with increased walking induced a score for SMI is an interesting fi nding. The predictive value for CS remains to signifi cant reduction in ABPM values in patients with type 2 diabetes and be determined in a larger sample of patients with CS. uncontrolled hypertension.

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A120 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

ABPM Values (mmHg): P* = Difference within Group; P† = Difference adjustment for age, gender, BMI, diabetes, hypertension, LDL cholesterol, between Groups (GLM). HDL cholesterol and smoking with a standardized adjusted hazard ratio (HR) Control Group Intervention Group of 1.41 [95% CI 1.16-1.72], p<0.001, as well as after additional adjustment for the presence and extent of CAD at the baseline angiography (HR 1.52 [95%CI Baseline End-of-study P* Baseline End-of-study P* P† 1.23-1.86], p<0.001). 24-h systolic 146.9 ± 14.9 144.3 ± 14.6 0.215 147.9 ± 11.8 132.6 ± 11.3 0.000 0.000 From this fi rst prospective evaluation of the cardiovascular risk associated 24-h diastolic 81.5 ± 8.9 78.3 ± 6.8 0.013 82.7 ± 8.0 75.2 ± 7.0 0.000 0.018 with plasma omentin we conclude that elevated omentin is a strong predictor of cardiovascular events independently from the presence of baseline CAD. Daytime systolic 148.3 ± 14.3 146.1 ± 15.6 0.343 151.3 ± 10.7 134.0 ± 9.4 0.000 0.000 POSTERS Supported By: Austrian National Bank Complications

Daytime diastolic 84.1 ± 9.6 81.7 ± 6.3 0.055 86.0 ± 8.3 77.7 ± 7.1 0.000 0.001 Acute and Chronic Night-time systolic 142.6 ± 17.7 135.9 ± 16.0 0.004 141.7 ± 16.0 128.5 ± 14.3 0.000 0.047 463-P Night-time diastolic 75.2 ± 8.6 72.6 ± 9.3 0.048 76.3 ± 7.8 70.8 ± 7.8 0.000 0.129 Heritability of Epicardial Adipose Tissue Compartment: Experience Supported By: CAPES; FIPE-HCPA; CNPq in a Classical Twin Study ADAM L. JERMENDY, DOROTTYA HORCSIK, TAMAS HORVATH, CSILLA CELENG, ESZTER NAGY, DAVID L. TARNOKI, BELA MERKELY, PAL MAUROVICH-HORVAT, 461-P GYORGY JERMENDY, Budapest, Hungary FGF21 Defi ciency Exacerbates Diabetic Cardiomyopathy by Aggra- Both diabetes mellitus and obesity are associated with an increased risk vating Cardiac Lipid Accumulation of coronary artery disease. It has been suggested that epicardial fat volume XIAOQING YAN, YI TAN, SHANSHAN ZHOU, ZHIGUO ZHANG, CHI ZHANG, LU is associated with coronary artery disease. Whether the epicardial adiposity CAI, Louisville, KY, Wenzhou, China depends on environmental infl uences or determined by genetic factors is Fibroblast growth factor 21 (FGF21) plays an important role in energy unclear. The aim of the study was to evaluate the genetic impact on the size homeostasis, but its effect on the development and progression of diabetic of epicardial adipose tissue within a sample of twin pairs. cardiomyopathy (DCM) has not been addressed before, which was thus In this study, 90 twin subjects (24 monozygotic [MZ] pairs with a mean age investigated in the present study with FGF21 knockout (FGF21-KO) diabetic of 57.0±8.9 years and 21 dizygotic [DZ] pairs with a mean age of 57.0±8.8 mice. Both FGF21-KO and C57BL/6J wild type (WT) mice were induced type 1 years) were involved. The twin pairs were investigated with a 256-slice diabetes by streptozotocin injection (50 mg/kg body weight daily for 5 days). CT-scanner (Brilliance iCT, Philips Healthcare, Best, The Netherlands). For At 1, 2 and 4 months after diabetes onset, these mice were examined for their each patient BMI, CT-based waist circumference (WC) and epicardial fat cardiac functions by echocardiograph and then sacrifi ced. Plasma triglyceride volume (EFV) were assessed. All phenotypic variables were screened for (TG) and FGF21 were measured. Cardiac lipid accumulation and fi brosis were outliers and normality. In absence of normality logarithmic normalization evaluated by Oil O Red staining and Sirius Red staining, respectively. Protein was performed. Concordance between MZ and DZ pairs were assessed by expression and phosphorylation were detected by Western blot. The results Pearson correlations. Rough heritability was calculated according to the indicated that FGF21-KO diabetic mice showed earlier and severer cardiac Falconer-method. dysfunction compared to WT diabetic mice. The plasma FGF21 levels were The mean BMI was 28.7±3.1 kg/m2, the mean WC was 103.0±2.8 cm, and signifi cantly decreased in WT diabetic mice compared to controls, but TG the median EFV was 85.2 [IQR: 61.6-106.1] cm3. A relatively high heritability levels were no difference between FGF21-KO and WT diabetic mice. Cardiac was found in both BMI values (0.74) and EFV values (0.626). lipid accumulation was signifi cantly more in FGF21-KO diabetic mice than In this classical twin study we were able to show that both BMI and that in WT diabetic mice. Western blots showed that FGF21-KO diabetic EFV have a relatively strong heritability. The potential role of EFV in the mice had signifi cant higher CD36 (a myocardial fatty acid uptake mediator) pathomechanism of coronary artery disease needs further investigation. expression and lower PGC1-α expression and phosphorylation of LKB1 Supported By: FESD and AMPK than WT diabetic mice, indicating an imbalance of cardiac lipid metabolism. The increased cardiac lipid accumulation also accompanied by 464-P signifi cant higher cardiac oxidative stress, indicated by up-regulation of 3-NT ProBNP Strongly Predicts Future Macrovascular Events in Angio- and 4-HNE, and cardiac fi brotic responses, indicated by Sirius Red staining graphied Coronary Patients With as Well as in Those Without the and CTGF and TGF-β expression in FGF21-KO DM. Our results demonstrated Metabolic Syndrome that FGF21 defi ciency-exacerbated cardiac lipid accumulation leads to the PHILIPP REIN, CHRISTOPH H. SAELY, ALEXANDER VONBANK, DANIELA ZANOLIN, increased cardiac oxidative stress and remodeling and, eventually, promotes HEINZ DREXEL, Feldkirch, Austria, Triesen, Liechtenstein, Philadelphia, PA the development of DCM. FGF21 might be a therapeutic approach for the Pro-B-type natriuretic peptide (proBNP) is a prognostic biomarker for treatment of DCM. patients with congestive heart failure as well as in other patient populations. Supported By: ADA (1-11-BS-17, 1-13-JF-53); NSFC (81273509, 81200239, The power of proBNP to predict cardiovascular endpoints in patients with the 81061120517, QTJ13007) metabolic syndrome (MetS) is unclear and is addressed in the present study. We measured serum proBNP in 722 patients undergoing coronary 462-P angiography for the evaluation of stable coronary artery disease (CAD). Plasma Omentin Signifi cantly Predicts Cardiovascular Events Signifi cant CAD was diagnosed in the presence of coronary stenoses with Independently from the Presence and Extent of Angiographically lumen narrowing of ≥50%. Prospectively, we recorded vascular events over Determined Baseline Coronary Artery Disease 3.2±1.2 years. ANDREAS LEIHERER, CHRISTOPH H. SAELY, AXEL MUENDLEIN, ALEXANDER ProBNP was signifi cantly higher in patients with (n=386) than in subjects VONBANK, PHILIPP REIN, KATHRIN GEIGER, CORNELIA MALIN, HEINZ DREXEL, without signifi cant CAD at baseline (711±1287 vs. 663±1565 pg/ml; p=0.001). Triesen, Liechtenstein, Feldkirch, Austria, Philadelphia, PA Prospectively, we recorded 121 cardiovascular events. The incidence of No prospective data on the power of the new adipocytokine omentin vascular events signifi cantly increased over tertiles of proBNP in patients to predict cardiovascular events are available. We therefore aimed at with the MetS (10.7%, 18.5%, and 28.8% respectively; p=0.004) was well investigating i) the association of plasma omentin with cardiometabolic as in those without the MetS (10.4%, 11.5%, and 22.0%, respectively; risk markers, ii) its association with angiographically determined coronary p=0.011). Similarily, serum proBNP signifi cantly predicted the incidence of atherosclerosis, and iii) the power of plasma omentin to predict cardio- major cardiovascular events after adjustment for age, gender, BMI, smoking, vascular events. systolic and diastolic blood pressure, LDL cholesterol, HDL cholesterol and We measured plasma omentin in a series of 295 patients undergoing the eGFR both in subjects with the MetS (standardized adjusted HR 1.48 coronary angiography for the evaluation of established or suspected stable [1.21-1.80]; p <0.001) and in those without the MetS (HR 1.21 [1.04-1.40]; CAD; presence of baseline CAD was defi ned as the presence of any lumen p=0.011). These results were not attenuated after further adjustment for irregularities at angiography; the extent of baseline CAD was defi ned as the the angiographically determined baseline CAD state (HRs 1.50 [1.23-1.83]; p number of signifi cant coronary stenoses ≥50%; prospectively cardiovascular <0.001 and 1.26 [1.09-1.47]; p=0.003 in subjects with the MetS and in those events were recorded over a mean follow-up period of 3.5 years. During this without the MetS, respectively). period, 17.6% of our patients suffered cardiovascular events, corresponding Serum proBNP predicts cardiovascular events independently of estab- to an annual event rate of 5.3%. Plasma omentin did not differ signifi cantly lished cardiovascular risk factors and of the baseline coronary artery state between patients with and subjects without signifi cant CAD (p=0.783), but both in patients with and in subjects without the MetS. prospectively omentin signifi cantly predicted cardiovascular events after Supported By: Austrian National Bank

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A121 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

465-P rats. The protocol included 2 big groups: control (C) and T2DM, each group Plasma Chemerin Is a Strong and Independent Predictor of Cardio- had 3 subgroups - 1) no drug administration (C and T2DM), 2) i/p metformin vascular Event Risk administration (200 mg/kg) for 3 days prior to the heart perfusion (CMi/p ANDREAS LEIHERER, AXEL MUENDLEIN, PHILIPP REIN, KATHRIN GEIGER, PETER and T2DMMi/p), 3) intraventricular (i/v) injection of metformin 50 mM during FRAUNBERGER, HEINZ DREXEL, ALEXANDER VONBANK, CHRISTOPH H. SAELY, 15 min of reperfusion period (CMi/v and T2DMMi/v). In all groups, global Triesen, Liechtenstein, Feldkirch, Austria, Philadelphia, PA cardiac ischemia-reperfusion was performed in the Langendorff isolated Associations of the adipokine chemerin with the metabolic syndrome perfused heart model followed by histochemical determination of infarct size. Phosphorylated α-AMPK was evaluated with Western blot analysis.

POSTERS (MetS) and with chronic kidney disease (CKD), two important indicators

Complications of increased cardiovascular event risk, have been described. However, the Infarct size was not different between C and CMi/p (45,0±10,4% vs. Acute and Chronic power of chemerin to predict cardiovascular events has not been investigated 55,6±15,8%), but was signifi cantly reduced in CMi/v - 29,3 ± 15,1 % (p=0,008). so far and is addressed in the present study. Infarct size in T2DM was signifi cantly lower than in controls (24.4±7.6% vs. We measured plasma chemerin in a high-risk cohort of 495 patients 45.0±10.4%, respectively, P<0.01), which is indicative of the phenomenon of undergoing coronary angiography for the evaluation of suspected or metabolic preconditioning in T2DM, but the administration of metformin had established coronary artery disease (CAD) in which cardiovascular events no appreciable effect on infarct size in T2DMi/p or T2DMi/v. In comparison were prospectively recorded over 3.5±1.1 years. Signifi cant baseline CAD to controls, α-AMPK phosphorylation was signifi cantly increased in T2DM was diagnosed in the presence of coronary artery stenoses ≥50%. and, to a lesser extent, in metformin-treated animals with the highest level At baseline, plasma chemerin was signifi cantly higher in patients with the in CMi/v and T2DMMi/v. MetS as defi ned by the current harmonized consensus defi nition (n=147) than Only intraventricular metformin administration to intact animals had in non-MetS subjects (201±71 ng/ml vs. 163±62 ng/ml p<0.001) and was cardioprotective effect and was correlated with the high AMPK activity. inversely correlated with estimated glomerular fi ltration rate (eGFR; r=-0.33, Metabolic preconditioning was also associated with AMPK activation and p<0.001). During follow-up, chemerin signifi cantly predicted cardiovascular further activation of AMPK by metformin didn’t have more cardioprotective events (n=82) univariately, after adjustment for age, gender, BMI, and eGFR, effect. and also after additional adjustment for the presence of signifi cant baseline CAD, with standardized hazard ratios of 1.83 [1.19-2.83], p= 0.006; 1.77 [1.12- 468-P 2.80], p =0.015; and 1.69 [1.07-2.67], p=0.024, respectively. Lipoprotein(a), Type 2 Diabetes, and Vascular Risk in Angiographied From this fi rst prospective evaluation of the cardiovascular event risk Coronary Patients associated with chemerin we conclude that chemerin is strongly predictive KARL M. EBNER, ALEXANDER VONBANK, CHRISTOPH H. SAELY, PHILIPP REIN, of cardiovascular events independently from standard risk factors, from the DANIELA ZANOLIN, HEINZ DREXEL, Triesen, Liechtenstein, Feldkirch, Austria, MetS, and from the baseline presence of CAD. Philadelphia, PA Supported By: Austrian National Bank Lipoprotein (a) [Lp(a)] especially in young individuals is an important cardiovascular risk factor. However, data on the long-term vascular risk 466-P conferred by Lp(a) in patients with type 2 diabetes (T2DM) are scarce. A Novel Nuclear Magnetic Resonance (NMR)-derived Systemic Lp(a) was measured in a cohort of 909 consecutive patients undergoing Infl ammatory Marker GlycA Is Associated with Cardiovascular Risk coronary angiography for the evaluation of established or suspected stable Factors in Overweight/Obese Subjects with Prediabetes coronary artery disease; vascular events were recorded over 10 years. TRUDY R. GAILLARD, LIANBO YU, KWAME OSEI, Columbus, OH Median Lp(a) at baseline was signifi cantly lower in patients with T2DM Background: Obesity and type 2 diabetes (T2DM) are considered as (n=260) than in subjects without T2DM (10 [interquartile range 1-34] vs. infl ammatory states. GlycA is a novel infl ammatory marker that has been 16 [1-54] mg/dl; p=0.017). Prospectively, 27.8% of our patients suffered proposed to be associated with T2DM and CVD. In the current study, we vascular events. Lp(a) proved to be a strong and independent predictor of examined the relationships between GlycA with risk factors for T2DM and vascular events in total population with a standardized adjusted hazard ratio CVD in prediabetic overweight/obese (OBS) subjects. (HR) of 1.15 [1.03-1.27]; p=0.006) as well as in subjects without T2DM (HR Subjects and Methods: We measured fasting serum GlycA (LipoScience, 1.22 [1.10-1.36]; p<0.001) but not in patients with T2DM (HR 0.990 [0.79- NC) in 112 (N= 72-Blacks and 40-whites) OBS prediabetic subjects, (mean 1.22]; p=0.888). An interaction term T2DM x Lp(a) was signifi cant (p<0.001), age- 46.5±11.2yrs, BMI- 37.8±6.3kg/m2, weight-105.5kg, SBP-128.6±14.3 and indicating that Lp(a) was a signifi cantly stronger predictor of vascular events DBP- 79.5±9.6mmHg, A1C-5.9±0.43%). Fasting lipids and lipoproteins, hsCRP in subjects without T2DM than in patients with T2DM. were obtained. Standard OGTT with fasting and 2 hour serum glucose (GLU), Lp(a) in patients with T2DM is low and is not associated with the incidence insulin (INS) and c-peptide (C-PEP) were obtained in all subjects. Insulin of vascular events. The power of Lp(a) as a predictor of cardiovascular events sensitivity (SI) was measured using FSIVGTT (MINMOD) and HOMA-IR. Body is signifi cantly modulated by the presence T2DM. composition was measured using BIA. Supported By: Austrian National Bank Results: We found, fasting and postprandial GLU (98.7±11.7 and 125.9±41.6mg/dl), INS (15.2±9.1 and 98.4±67.9uU/ml) and C-PEP(3.10±1.4 and 469-P 11.9±4.7ng/ml) were within normal limits. Fasting GlycA was (405.2±64.5) Presence of T2DM Signifi cantly Modulates the Power of TSH to and hsCRP (8.2± 9.3 mg/dl). After adjusting for age, race, weight, A1C, Predict Cardiovascular Mortality fasting GLU and INS, we found signifi cant relationships between hsCRP and DANIELA ZANOLIN, ALEXANDER VONBANK, PHILIPP REIN, CHRISTOPH H. SAELY, GlycA (r=0.092, p=<0.00 01) in our study. We found no relationship between HEINZ DREXEL, Triesen, Liechtenstein, Feldkirch, Austria, Philadelphia, PA GlycA and A1c (r=0.001, p=0.105), ApoA1 (r=0.065, p=0.08), ApoB (r=0.01, Elevated thyroid stimulating hormone (TSH) is associated with an adverse p=0.76), triglycerides (r=-0.07, p=0.34) or HDL (r=-0.003, p=0.85). cardiovascular risk profi le, especially in patients with type 2 diabetes Conclusion: GlycA is a novel infl ammatory marker that has potential (T2DM). We investigated the association between TSH and cardiovascular to be associated with the risk for T2DM and CVD in OBS subjects with mortality in patients with T2DM as well as in non-diabetic subjects. prediabetes. Further studies are warranted to elucidate the utility of GLycA We measured TSH in a high-risk cohort of 1741 consecutive patients in ethnic populations at high risks for T2DM and CVD. undergoing coronary angiography for the evaluation of established or suspected Supported By: ADA (1-11-CT-39); CTSA (UL1TR001070) coronary artery disease (CAD). The incidence of vascular events was recorded over 10 years; T2DM was defi ned according to current ADA criteria. 467-P From our patients, 34% suffered vascular events. TSH proved to be a The Effect of Metformin on Cardioprotection and AMPK Activity in strong and independent predictor of cardiovascular mortality in subjects Experimental Model of Type 2 Diabetes Mellitus without T2DM (n=1220; standardized adjusted hazard ratio (HR) 1.11 [1.00- EKATERINA N. KRAVCHUK, ELENA N. GRINEVA, MIKLE M. GALAGUDZA, ANNA 1.24]; p=0.036), but not in patients with T2DM (n=521; HR 0.99 [0.87-1.14]; A. KOSTAREVA, Saint Petersburg, Russian Federation p=0.934). An interaction term TSH x T2DM was signifi cant (p=0.039), The aim of our study was to fi nd out the action of metformin on myocardial indicating that TSH was a signifi cantly stronger predictor of vascular events tolerance to ischemia-reperfusion injury and cardiac AMP-activated protein in subjects without T2DM than in patients without T2DM. kinase (AMPK) activity and to compare different ways of metfromin From the data of this prospective cohort study we conclude that presence administration. of T2DM signifi cantly modulates the power of TSH to predict cardiovascular Type 2 diabetes mellitus (T2DM) was induced with single intraperitoneal mortality. (i/p) injection of streptozotocin at a dose of 65 mg/kg to newborn Wistar Supported By: Austrian National Bank

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A122 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

470-P development of diabetic vascular complications. However, impact of glucose 24-Hour Blood Pressure Homeostasis in Subjects with Different fl uctuation on systemic vascular stiffness still remains unknown. To clarify Degrees of Glucose Tolerance this issue, we evaluated the relationship between MAGE and cardio-ankle VANESSA PICCOLI, TÁSSIA C. PAZINATO, BÁRBARA L. NEDEL, LUCIANA P. vascular index (CAVI), an established surrogate marker for cardiovascular ANTONIOLLI, LUCAS GATELLI, MAYARA A. BEER, FILIPE V. NASCIMENTO, ANIZE disease, in 58 patients including 22 women with type 2 diabetes mellitus. DELFINO VON FRANKENBERG, FERNANDO GERCHMAN, Porto Alegre, Brazil MAGE and mean blood glucose (MBG) were obtained from subcutaneous It is not clearly defi ned which factors affect blood pressure (BP) homeo- interstitial glucose levels which were monitored over a period of 24 hours by using CGMS System Gold (Medtronic MiniMed, Northridge, CA, USA). stasis along the day and how they affect BP circadian rhythm in subjects POSTERS with different degrees of glucose tolerance (GT). The aim was, therefore, CAVI was measured with a VaSera VS-1000 (Fukuda Denshi Co. Ltd, Tokyo, Complications to analyze differences in the circadian rhythm of BP and its possible Japan). Acute and Chronic determinants in subjects with different degrees of GT. In a cross-sectional The mean ± SD of age, HbA1c, MAGE, MBG and CAVI were 65.3 ± 12.3 design, 118 subjects (53.4± 2.5 y, females 70.3%) were submitted to a 75-g years, 8.8 ± 2.0%, 88 ± 33mg/dl, 182 ± 42mg/dl and 9.0 ± 2.1, respectively. OGTT after overnight fast (normal GT [NGT; n=33], prediabetes [PDM; n=51] In univariate regression analysis, CAVI was signifi cantly correlated with and diabetes [DM; n=34]). 24-h ambulatory blood pressure monitoring age (r = 0.307, p = 0.019), MAGE (r = 0.271, p = 0.040), respectively. The multiple (ABPM) was performed. Blood and urinary samples were collected for linear regression analysis showed that CAVI was signifi cantly associated determination of biochemical and hormonal profi le. Body size (BMI), central with MAGE (standardized estimate = 0.309, p = 0.028) after adjustment for obesity (waist to hip ratio; WHR), insulin sensitivity index (ISI Stumvoll), conventional risk factors. This association still remained signifi cant when β-cell function (insulinogenic index; ΔIns30’-0’/ΔGli30’-0’) and glomerular MBG was additionally incorporated into independent variables. fi ltration rate (eGFR; CKD-EPI) were estimated. By ABPM, 24-hour systolic In conclusion, this study suggested that glycemic variability may cause the BP (SBP) progressively increased from NGT to DM (NGT 121.0 ± 15.5 vs. development of systemic atherosclerosis in a manner independent of HbA1c PDM 128.5 ± 14.3 vs. DM 136.8 ± 18.2 mmHg; P<0.001). The same pattern and MBG levels in patients with type 2 diabetes. was found with daytime (P=0.001) and nighttime ABPM (P=0.001). 24-hour SBP was positively related to age, BMI, WHR, 2-h glucose, C-peptide, 473-P plasma cortisol and UAE, whereas it was inversely related to scholarity, ISI The Effect of Basal Insulin Therapy on Endothelial Function in Type Stumvoll, ΔIns30’-0’/ΔGli30’-0’, pancreatic polipeptide and eGFR. According 2 Diabetic Patients to 24-h ABPM, BP levels increase with decreasing GT after adjustment HISASHI MAKINO, AI HISHIDA, RYO KOEZUKA, MAYU TOCHIYA, YOKO OHATA, for confounding variables (NGT vs. PDM [P=0.031] and NGT vs. DM TAMIKO TAMANAHA, ICHIRO KISHIMOTO, Suita, Japan [P<0.001]). Insulin sensitivity, education, age, central obesity, postprandial Background: Basal insulin therapy addition to oral hypoglycemic drugs is hyperglycemia, β-cell dysfunction, renal function and counterregulatory useful and commonly used to achieve glycemic control in type 2 diabetes. hormones are possible determinants of 24-h BP levels and its behavior in This study aimed to compare the effect on endothelial function and subjects with different degrees of GT. adipocytokine of basal insulin glargine and detemir. Supported By: CNPq; CAPES; FAPERGS Methods: We studied 32 type 2 diabetic patients whose blood glucose control were unsatisfactory by using oral hypoglycemic drugs. Patients 471-P were randomized to either insulin glargine or detemir for 24 weeks and then Circulating Soluble Insulin Receptor Is Associated with Cardiac crossed over to the other treatment without washout period. Endothelial Dysfunction in Type 2 Diabetic Subjects function by fl ow mediated vasodilatation (FMD), and adipocytekine level YASUNORI TAKATA, RYOICHI KAWAMURA, HIROSHI ONUMA, TOMOYUKI (PAI-1, and leptin/adiponectin ratio) were monitored. YUASA, HARUHIKO OSAWA, Toon, Japan, Tokushima, Japan Results: HbA1c level was signifi cantly decreased by both basal insulin The presence of diabetes substantially increases the risk of heart failure therapy. Body weight was signifi cantly increased by glargine but not detemir. (HF) and it may indicate a poor prognosis even after considering blood FMD was signifi cantly increased by both insulin therapy, particullary detemir pressure (BP) and coronary artery disease (CAD). Previous animal studies (glargin; 5.17 ± 0.69 → 5.94 ±0.83%, detemir; 4.89 ± 0.78→ 7.92 ± 0.69%). showed that reduced cardiac insulin signaling has been thought to be one PAI-1 was signifi cantly decreased by only detemir (glargin; 16.4 ± 1.8 → of the important mechanisms of HF in diabetes. However, it is diffi cult to 17.3 ± 2.1, detemir; 19.2 ± 2.8→ 16.0 ± 1.6). Leptin/adiponectin ratio was evaluate the infl uence of impaired insulin signaling on cardiac function in signifi cantly increased only glargine. humans. Recent studies have demonstrated that soluble insulin receptor Conclusions: These results suggest that the effect on endothelial function (sIR) is elevated in blood of diabetic patients. Furthermore, ex vivo study and adipocytekine profi les may differ between glargine and detemir in and animal study demonstrated that the circulating sIR potentially prevents diabetic patients. insulin action in vivo, working as “decoy receptor”. Thus, we hypothesized that circulating sIR levels may be associated with cardiac-dysfunction. To 474-P identify the relation between sIR and cardiac-dysfunction in subjects with Basal Insulin Therapy Reduces Hepatic Fat but Increases Circulating type 2 diabetes (T2DM), we performed a retrospective study of sequential GDF-15 Plasma Concentrations 152 T2DM and 150 non-diabetic subjects (NDM) by echocardiography and LANA KOSI, MAREK CHMELIK, IVICA KUKUROVA, SIEGFRIED TRATTNIG, measuring plasma sIR. Simple regression analysis revealed that sIR was ALEXANDRA KAUTZKY-WILLER, Vienna, Austria positively correlated with fasting plasma glucose and HbA1c. Furthermore, Increased liver fat is strongly associated with type 2 diabetes and sIR was positively correlated with the ratio of early transmitral fl ow velocity cardiovascular risc. Insulin therapy increases body weight, whereas the to tissue doppler early diastolic mitral annular velocity (E/e’), and inversely effect on ectopic liver fat content is less clear. The aim of this study correlated with left ventricular ejection fraction (LVEF) (R=0.24 and R=-0.19, was to investigate the effect of basal insulin therapy-add on in patients respectively; p<0.05 each) in T2DM but not in NDM. Multivariable regression recieving oral antidiabetic agents on hepatic fat content and adipokine analysis revealed that sIR was independently associated with E/e’ and levels. LVEF after adjustment for age, gender, BMI, BP, eGFR, antihypertensive 21 patients (11 male, 10 female age ) with T2DM and HbA1c>7% treated treatment, and the prevalence of CAD in T2DM (βsIR=0.29, and βsIR=-0.24, at our outpatient clinic of the Medical University of Vienna were included respectively; p<0.01 each), but not in NDM. On the other hand, BNP was in the study. All underwent magnetic resonance spectroscopy which signifi cantly associated with LVEF and E/e’ in NDM as well as T2DM. Our was performed with 3 Tesla Siemens MRT. Adiponectin and Leptin were results suggest the possibility that sIR is related to the pathophysiology of measured by RIA kits, GDF-15 by ELISA. diabetes-associated cardiac-dysfunction. The mean age of the 21 patients was 55,9±7,2 years, weight 88,3±17 kg, BMI 31,6± 5,1kg/m2 and duration of diabetes 6,1±3,2 years. After 6 months 472-P of therapy HbA1c decreased signifi cantly (8.7±0.2% to 7.5±0.3%, p<0.0001) Elevated Cardio-Ankle Vascular Index (CAVI) Is Associated with at a mean insulin dose of 30±4 units, followed by a weight-increase of Wide Glycemic Variability in Patients with Type 2 Diabetes 2,3±1,1 kg, no signifi cant sex differences respectively. Liver fat decreased MIWA MORITA, MASAHIRO YAMAMOTO, TOSHITSUGU SUGIMOTO, Izumo, from 15,1±4,2% to 8,12±3,46% (p=0,04) and correlated negatively with Japan Adiponectin and GDF-15 (p=0,04 and p=0,01 respectively) and positively In addition to HbA1c levels, the mean amplitude of glycemic excursions with Leptin (p=0.04). (MAGE), which is calculated from data of continuous glucose monitoring Basal insulin therapy reduces, independent of weight, hepatic fat system (CGMS), is an important index for diabetic patients to prevent content after already 6 months of therapy. However the increase of GDF- 15

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A123 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

concentrations could be of prognostic value regarding cardiovascular risc. 477-P Bigger studies focusing on the effect of insulin therapy on cardiovascular risc HMG-CoA Reductase Inhibitors Prevent Cerebrovascular Attack via and myocardial function are needed to be able to explain these preliminary a Direct Effect in Type 2 Diabetic Patients, Including Late Elderly fi n d i n g s . TOSHIO HAYASHI, KIYOSHI KUBOTA, KOUTARO YOKOTE, MINORU TAKEMOTO, MITSUHIKO NODA, HIROSHI NOTO, HIROHITO SONE, ATSUSHI ARAKI, KOICHIRO 475-P INA, HIDEKI NOMURA, JAPAN CDM GROUP, Nagoya, Japan, Tokyo, Japan, Chiba, Inverse Association between Serum Bilirubin Levels and Arterial Japan, Mito, Japan

POSTERS Stiffness in Korean Subjects with Type 2 Diabetes Low-density-lipoprotein-cholesterol (LDL-C) is a risk factor for ischemic Complications EUN SOOK KIM, EUN YOUNG MO, SUNG DAE MOON, JE-HO HAN, MI KYOUNG heart disease(IHD), and HMG-CoA reductase inhibitors(statins), can reduce Acute and Chronic KIM, Incheon, Republic of Korea, Daegu, Republic of Korea that risk in middle-aged diabetic individuals. However, the risk associated Considerable evidence suggests that bilirubin acts as a potent physiologic with LDL-C and the preventive effects on cerebrovascular attack(CVA) have antioxidant that may provide important protection against cardiovascular not been identifi ed, especially in the elderly. We performed a prospective disease (CVD) and infl ammation. cohort study(Japan Cholesterol and Diabetes Mellitus Study) with 5.5 We investigated the relationship between serum total bilirubin (TB) years of follow-up. We recruited 4,014 type 2 diabetic patients without concentrations and arterial stiffness measured by brachial-ankle pulse previous IHD or CVA(n=1,936 women; age=67.4±9.5 years; ≥75years:late wave velocity (baPWV) in patients with type 2 diabetes. We conducted a elderly, n=1,016) throughout Japan. We fi rstly registered 405 sub-cohort cross-sectional analysis of 2059 subjects with type 2 diabetes (986 men patients. We recorded information on medications and laboratory data after and 1073 women; mean age 57 years). Subjects were stratifi ed according to changes in medications in sub-cohort patients and patients suffered from gender-specifi c tertile of total bilirubin values and a high baPWV was defi ned IHD or CVA. We divided statin users into prevalent, new and non-users.In as greater than 1749 cm/s (>75th percentile). BaPWV decreased gradually accordance with the original study, this case-control study was performed. with TB tertile in. both genders. After adjustment for age, body mass index, Being different from the standard case-control study, controls (subcohort smoking, alcohol intake, diabetes duration, HbA1c, alanine aminotransferase, members) were randomly selected from the entire cohort (case-cohort hypertension, hyperlipidemia, previous CVD, and use of insulin, the TB levels study) and analyzed by the Barlow’s method. A total of 153 IHD cases and were inversely associated with a greater risk of high baPWV, both as a 104 CVAs occurred during 5.5-year. HDL-C level was correlated with CVA continuous variable [a 1-SD difference, odds ratio (OR), 0.49; 95% confi dence in patients≥65 years. In sub-cohort study, among the patients prescribed interval (CI), 0.31-0.78; P = 0.003] and when categorized in tertiles (the no agents for dyslipidemia, CVA prevalence increased age-dependently. highest vs. the lowest tertile, OR, 0.55; 95% CI, 0.36-0.84; P = 0.005) in CVA incidence was lower in prevalent and new users of statins than in women but not in men. The relationship remained signifi cant even after non-users(HR:0.460, 0.523), especially in late elderly(HR:0.51, 0.21). We additional adjustment for retinopathy and nephropathy. In conclusion, TB analyzed the effects of treatment, especially the statins’ effect on CVA levels are inversely associated with arterial stiffness in Korean women with risk, and observed that the reduction of CVAs by statins was due to a direct type 2 diabetes. Our data raise the hypothesis that bilirubin may protection effect and partially the effects of HDL-C and glucose metabolism. These against macrovascular disease in patients with type 2 diabetes. new fi ndings could provide additional data for the annotation of CVA risk in diabetics. Statin treatment may prevent CVA in middle-aged and elderly 476-P diabetic patients, mainly via a direct effect. Supported By: Ministry of Health, Labour and Welfare A Comparison of Continuous Intravenous Insulin and Subcutaneous Insulin among Patients with Type 2 Diabetes and Congestive Heart Failure Exacerbation 478-P KATHLEEN M. DUNGAN, KWAME OSEI, TRUDY R. GAILLARD, JARED MOORE, Resting Heart Rate, Heart Rate Variability, and Mild Hypoglycemia PHILIP BINKLEY, Columbus, OH during the Diabetes Control and Complications Trial and Follow-up Glycemic variability (GV) is associated with mortality in congestive heart Study (DCCT/EDIC) failure (CHF) but the mechanism is unknown. Since insulin absorption may ELKE FAHRMANN, LAURA ADKINS, CAMERON LOADER, KEVIN RICE, HENRY be impaired in CHF, this study investigates whether the route of insulin DRISCOLL, Huntington, WV infl uences GV and infl ammatory or neurohormonal markers in patients with Purpose: The jury on the role of hypoglycemia on cardiovascular type 2 diabetes (T2D) hospitalized for CHF. disease (CVD) is still out. It has been speculated that in type 1 diabetes Patients (N=65) were randomized to intravenous (IV) insulin (duration 48 nonsevere (mild) hypoglycemia might have a stronger role in CVD than hours) or subcutaneous (SQ) insulin. Brain natriuretic peptide (BNP), Cytokines severe hypoglycemia. It has been found that intensive treatment of type 1 (C-reactive protein, interleukin-6), and measures of oxidative stress (oxidized diabetes was associated with a lower resting heart rate (RHR) which might LDL, paraoxonase-1 activity) were measured at baseline and day 3. High have contributed to a reduced CVD risk. It has been also established that frequency heart rate variability (HF HRV, N=27) and cardiac impedance (pre- reduced heart rate variability (HRV) is associated with an increased risk of ejection period, PEP, N=28) were used to estimate parasympathetic and malignant arrhythmias and mortality. So far no studies on mild hypoglycemia sympathetic tone respectively in patients with valid cardiac data. GV was and RHR/HRV exist. Our goal is to evaluate whether correlations between measured using a continuous glucose monitor. mild hypoglycemia and RHR/HRV in type 1 diabetes exist. Mean glucose was lower (7.7 vs. 9.4 mmol/, p=0.004), coeffi cient of Methods: Publicly available NIDDK repository DCCT/EDIC data were variation was higher (24.5 vs. 18.6%, p=0.03), and glycemic lability index evaluated. The study included the entire DCCT cohort. Mild hypoglycemia was similar on day 1 in the IV group compared to the SQ group respectively. events were reported for the seven days prior to the quarterly DCCT or Measures of glycemic control were similar by day 2. The IV group had annual EDIC visits. For the repeated measures of RHR or HRV (using R-R more confi rmed hypoglycemia events overall (p=0.005) but time spent in variation and Valsalva ratios) multilevel models were applied to assess an hypoglycemia was no different and there were no severe events. There association with mild hypoglycemia. Models were adjusted for clinically were no differences in CHF biomarkers, HF HRV or PEP between groups. relevant factors such as age, gender, A1C, exercise and smoking. Increasing log GLI was inversely correlated with on-treatment PEP (r= -0.41, Results: Signifi cant negative correlations adjusted for age and gender p=0.03) but not with other biomarkers; other glucose measures were not were found between mild hypoglycemia rates (current and updated related to PEP or other biomarkers. cumulative mean) and RHR during DCCT and EDIC (p<0.01). Even after In conclusion, despite modest differences in glucose control, the analyses adjustment for A1C and exercise, the correlation remained signifi cant for do not support a link between method of insulin administration and systemic updated cumulative mild hypoglycemia (p<0.05) but not for current. There infl ammation, oxidative stress, or cardiac autonomic tone in hospitalized CHF was a signifi cant association between A1C and HRV but there was no patients. GV may be associated with increased cardiac sympathetic activity, association between HRV and mild hypoglycemia. but it was not associated with adverse changes in CHF biomarkers. Conclusion: Results of mild hypoglycemia on RHR cannot be fully Supported By: Ohio State University (UL1RR025755) explained by A1C. The effects of both reversible adaptation to hypoglycemia and irreversible autonomic neuropathy on HR and CV outcome warrant more investigations to understand the role of hypoglycemia in CVD better.

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A124 COMPLICATIONS—MACROVASCULAR—ATHEROSCLEROTIC CARDIOVASCULAR DISEASE AND HUMAN DIABETES

479-P 481-P What Happens When Type 2 Diabetic Patients Fall Asleep? Charac- Comparison of Left Ventricular Filling Pressures and Endothelial teri zation of Electroencephalography Features Function in Male Type 2 Diabetic Patients with Normal or Low Total ALBERT LECUBE, ODILE ROMERO, GABRIEL SAMPOL, FERRAN RIUS, CRISTINA Testosterone Levels HERNÁNDEZ, JORDI MESA, CARLOS ZAFON, ANA CASTERÀS, OLGA MESTRES, JAVIER M. FARIAS, MATIAS TINETTI, Buenos Aires, Argentina RAFAEL SIMÓ, Lleida, Spain, Barcelona, Spain Type 2 Diabetes (T2D) increase risk of heart failure (HF) frequently left There is growing evidence suggesting than type 2 diabetes mellitus ventricular fi lling pressures (LVFP) is increased before symptoms appear.

(T2DM) is an independent risk factor for severe nocturnal hypoxemia and Serum testosterone can mediate LVF abnormalities affecting endothelium POSTERS sleep breathing disorders. However, it is unknown whether these sleep mediators generation. The association between LT levels, endothelial Complications disturbances affect the structure of sleep. For this purpose we designed a function and LVF in male diabetic patients are unknown The aim was to Acute and Chronic case-control study between 28 T2DM patients and 56 non-diabetic subjects, compare LVFP and presence of endothelial dysfunction (ED) in male patients closely matched by age, gender, BMI, waist and neck circumferences, smoking with T2D with normal and low testosterone (LT) levels. status, and the apnea-hypopnea index (IAH). The exclusion criteria included We included male patients with T2D, a tissue Doppler imaging assessment chronic respiratory disease, neuromuscular and cerebrovascular disease, of LVF pressures by passive transmitral left ventricular infl ow velocity to alcohol abuse, use of sedatives, and pregnancy. Examination included a tissue Doppler imaging velocity of the lateral mitral annulus during passive electroencephalography and respiratory polysomnography. No differences fi lling (E/e’ ratio) and a fl ow mediated dilation test on brachial artery to in the Rapid Eye Movement (REM) Sleep (13.5±8.2 vs. 12.8±7.4 % of total detect those with ED excluding patients with HF, myocardiopathies, and time of sleep, p=0.689) nor in the Non-Rapid Eye Movement (NREM) Sleep compare them depending low ( ≤ 3,5 ng/ml, group A) or normal ( > 3,5 ng/ml, stages (stage 1: 18.6±12.4 vs. 15.1±13.0 %TTS, p=0.243; stage 2: 58.1±14.0 vs. group B) total testosterone. 59.3±12.5 %TTS, p=0.688; stage 3: 12.5±10.5 vs. 12.3±10.2 %TTS, p=0.924; Data were analyzed using simple calculation, Mann Whitney U tests. stage 4: 13.8±10.8 vs. 12.4±10.4 %TTS, p=0.594) were observed between Odds ratio [OR] and 95% confi dence intervals (CI) were calculated using subjects with and without T2DM. However, T2DM patients showed a higher simple and multiple logistic regression A total of 178 patiens were included: number of microaurousals (or brief awakenings) events than control subjects Group A n=43, 24.2% and group B 75.8 %. Mean age was 56.8 years (±7, [34.1 (4.6 to 101.4) vs. 22.7 (1.3 to 93.1) events per hour during the TTS, 1) and time of T2D evolution 6.7 years (±3, 3). There was no difference p=0.023]. A signifi cant positive correlation between microarousals and the between groups on age, time of T2D, HbA1C, hypertension, heart rate, BMI AHI was detected (r=0.807, p<0.001). Finally, a stepwise regression analysis and echocardiographic parameters. Group A has E/e’ ratio 8,05 ±1, 9, group showed that both the AIH and the presence (or not) of T2DM (but not gender, B: 6,1±1,7 p<0, 001; presence ED 80,5% and 42,1% p 0,0001 respectively. age, BMI, neither neck circumference) independently predicted the presence Logistic regression analysis shows increased risk of E/e’ higher than 8, for of microarousals (R2=0.593). Therefore, T2DM adversely affects structure of patients with ED OR=8.75 (3.59-21.3), p<0. 0001, and LT=4.08 (1.37-12.07), sleep, becoming an independent risk factor for higher rates of microarousals. p 0.0001. Adjusted OR remained signifi cant age, time of T2D, HbA1C, As sleep fragmentation has been involved with increased levels of lipids and hypertension, lipids, treatments and BMI. Male patients with T2D and LT blood pressure, this increased rate of microarousals may be implicated in the levels have higher LVFP and more ED. These fi ndings are independent of progression of cardiovascular disease in T2DM. cardiovascular risk factors and echocardiographic parameters. Supported By: ISCIII FIS 12/00803; Sociedad Española Endocrinología y Nutrición 482-P The Relationship between Glycemic, Blood Pressure, and Choles- 480-P ter ol Control and Mortality: Evidence from a Community-based Cognitive Impairment in Patients with Type 2 Diabetes and Metabolic Endocrinology Practice Syndrome Is Related to Worsening Glycemia and Cardiovascular GRETCHEN PIATT, SWARNA VARMA, Ann Arbor, MI, Bridgeville, PA Factors Evidence demonstrates that diabetes increases mortality approximately DIVYA YOGI-MORREN, POOJA MANROA, SARAH STRANDJORD, LAURENCE two-fold and macrovascular disease, including coronary artery disease KENNEDY, MARWAN HAMATY, JOHN P. KIRWAN, JOHN GUNSTAD, SANGEETA (CAD), is the principal cause of death. However, prevention of CAD and R. KASHYAP, Cleveland, OH, Kent, OH ultimately decreased mortality is achievable through glucose (A1c), blood Clinical studies have noted a greater prevalence of global cognitive pressure (BP), and cholesterol (LDL) control (ABCs). We therefore aimed impairment, cognitive decline and Alzheimer’s disease in type 2 diabetes(T2D). to examine mortality rates in individuals with and without CAD who have However, the clinical factors that underlie cognitive decline in T2D are not ABCs controlled to goal levels in a community-based endocrinology practice well understood. We performed a prospective, longitudinal cohort study (CBEP) over 10 years. 385 consecutive patients seen in consultation for with repeated measures in 34 adults with T2D (age 57.6 ± 12.4 years, 55.9% diabetes management in a CBEP comprised the analysis cohort. To be female, average T2D duration 10.4 ± 9.6 years, HbA1c 7.4 ± 2.0, 38.2% insulin included, a patient had ≥ 2 A1C, BP, and LDL measurements respectively users). Participants completed the Webneuro cognitive test battery and without prevalent CAD. All patients were 18 years or older with a diagnosis measures were selected to assess verbal memory (Sum of Learning Trials 1-3, of diabetes before or during calendar year 2000 (100% identifi ed using ICD- Recognition), attention (Verbal Interference Part 1), and executive function 9 codes, problem lists, medication, or labs). Average age was 61.9 years, (Verbal Interference Part 2). Tests were performed at baseline and follow 92.8% were Non-Hispanic white, and 60% were female. At baseline, 60.1% up within 1 year to determine the change in performance over time. Each had A1c < 7%, 44.9% had BP < 130/80 mmHg, and 73.3% had LDL < 100 mg/ visit also documented clinical and biochemical data. 59.3% of participants dL. 22.1% had all ABCs in control. 17.6% of individuals developed incident exhibited cognitive impairment at baseline on at least 1 component of CAD over 10 years. The overall mortality rate was 6.6 per 1000 person years. cognitive function (> 1 SD below normal performance). Repeated measures A 30% reduction in incident CAD occurred in patients who improved all MANOVA revealed cognitive decline over time (λ = 0.48, F = 5.63, p = .0003) ABCs to goal levels during the time they were seen in the practice (HR=0.7, with poorer performance emerging on multiple measures (e.g. Recognition, p=0.05). Mortality rates followed suit with signifi cantly lower mortality p =.04, Verbal Interference Part 1, p<.001). Partial correlations revealed that rates observed in individuals with all ABCs in control, despite their CAD glycemic control, higher HbA1c was related to poorer performance on verbal status. These results highlight the feasibility of achieving ABC goals and Interference part 1, (r = 0.62, p<.001), higher total cholesterol was related to demonstrate the signifi cant impact that ABC control has on incident CAD poorer performance in recognition, (r =0.40, p=.04) and higher diastolic blood and mortality in a CBEP. Models of care that focus on secondary prevention pressure was related to poorer performance on verbal Interference Part 1 of complications may lead to decreased morbidity and mortality. (r = 0.43, p =.03). These fi ndings indicate that cognitive decline is common in T2D patients with metabolic syndrome and linked to both glycemic and cardiovascular factors. Future studies are needed to confi rm this fi nding and identify the potential value of intensive intervention to improve clinical and cardiovascular parameters on cognitive outcomes in patients with T2DM and metabolic syndrome.

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A125 COMPLICATIONS—MACROVASCULAR—CELLULAR MECHANISMS OF ATHEROGENESIS IN DIABETES

COMPLICATIONS—MACROVASCULAR—CELLULAR I/R-induced myocardial injury while vascular caveolae-dependentAT1R MECHANISMS OF ATHEROGENESIS IN DIABETES signaling inhibits coronary BK channel activity and exacerbates I/R- induced myocardial infarction in diabetes. Supported By: ADA (1-12-BS-119); NIH Guided Audio Tour: Cardiovascular Disease and Diabetes—Basic and Animal (Posters: 483-P to 490-P), see page 15. & 485-P TLR4 Antagonist Reduces Atherosclerosis in Diabetic LDL Receptor-

POSTERS & 483-P Defi cient Mice Complications Cardiac Oxidative Stress Relates to Ischemic Intolerance in Insulin ZHONGYANG LU, XIAOMING ZHANG, YANCHUN LI, MARIA F. LOPES-VIRELLA, Acute and Chronic Resistant Mice YAN HUANG, Charleston, SC TOMAS JELENIK, ULI FLOEGEL, OLESJA RITTER, ILKA ROKITTA, JÖRG KOTZKA, Although we have reported that toll-like receptor (TLR)4 antagonist MICHAEL RODEN, JULIA SZENDROEDI, Düsseldorf, Germany reduces atherosclerosis in mouse model for type 1 diabetes, it remains Non-alcoholic fatty liver (NAFL) and insulin resistance relate to undetermined if TLR4 antagonist also attenuates atherosclerosis in cardiac mortality. Humans with type 2 diabetes (T2D) can have impaired mouse model for type 2 diabetes. In this study, we employed male low- mitochondrial function in skeletal muscle and liver. We hypothesized that density lipoprotein (LDL) receptor-defi cient (LDLR-/-) mice as the model for cardiac energy metabolism is altered in mice with NAFL. atherosclerosis and induced type 2 diabetes by feeding high-fat diet (HFD). Female mice, 36 weeks, with adipose tissue-specific overexpression At 10 weeks old, 20 mice were fed HFD and 20 mice fed regular chow for 5 of sterol regulatory-element binding protein-1c (aP2-SREBP-1c), months. In the last 10 weeks of the 5 months, half HFD-fed mice and half lipodystrophy and NAFL due to hyperlipidemia, (AP2) and wild-type regular chow-fed mice were treated with R. sphaeroides lipopolysaccharide controls (CON) underwent hyperinsulinemic-euglycemic clamps (n=5- (Rs-LPS), an established TLR4 antagonist (1 µg/mouse, twice a week, 7). Systolic blood pressure was measured in the left ventricle (n=5). intraperitoneal injection). Following the euthanasia, atherosclerotic lesions Respiration and reactive oxygen species production of cardiac isolated on aortas were quantifi ed. Results showed that HFD feeding signifi cantly mitochondria were assessed by high-resolution respirometry and Amplex increased glucose (317 vs. 228 mg/dl) and body weight (54.44 vs. 26.08 Red (n=6-8). Cardiac function, lipids and morphology was measured by g/mouse). HFD also remarkably increased plasma lipids including total magnetic resonance imaging (n=8) before and 7 days after myocardial cholesterol, triglycerides, LDL and free fatty acids, and insulin. All these ischemia-reperfusion. metabolic data indicate that the HFD feeding induced type 2 diabetes in Whole body glucose disposal a was 70% lower in AP2 mice than in CON LDLR-/- mice as the mice had hyperglycemia, obesity, dyslipidemia and (p<0.05). AP2 mice had 34% increased heart to body weight ratios, increased hyperinsulinemia. Furthermore, results showed that treatment with Rs-LPS cardiac wall thicknesses in dia- and systole associated with a 40% rise in did not change HFD-increased glucose, lipids and insulin in both nondiabetic myocardial mass (p<0.05) and almost 100% increased cardiac lipids. Systolic and diabetic mice. In the analysis of atherosclerosis, results showed that blood pressure was comparable to CON (93±8 vs. 89±6 mmHg, n=5). Cardiac atherosclerotic lesions in diabetic mice were increased when compared to mitochondrial oxidative capacity on glycolytic substrates and β-oxidation- nondiabetic mice (p<0.01). While Rs-LPS had no effect on atherosclerosis in derived substrates was 93% and 125% higher in AP2 mice. H2O2 production nondiabetic mice, it reduced atherosclerosis in diabetic mice signifi cantly by mitochondrial complex III was doubled (p<0.05) in AP2 mice, compared to (p<0.05). Taken together, this study demonstrated for the fi rst time that CON. In AP2 mice ejection fraction was unchanged at normal perfusion but although TLR4 antagonist had no effects on the metabolic abnormalities in 7 days after myocardial infarction failure of heart function was 26% more mice with type 2 diabetes, it signifi cantly attenuated diabetes-associated pronounced compared to CON (p<0.05). atherosclerosis. The attenuation of atherosclerosis by Rs-LPS is likely due to Insulin resistance and steatosis relate to high oxidative capacity, inhibition of vascular infl ammation. substrate shift towards lipids and oxidative stress. High energy turnover Supported By: U.S. Dept. of Veterans Affairs; NIH (R01DE016353) can result from hyperlipidemia and cardiac hypertrophy, which is not caused by hypertension. Oxidative stress could underly ischemic intolerance and & 486-P promote cardiac mortality of patients with T2D. Secretory Products from Perivascular Adipose Tissue from Patients Supported By: German Research Foundation; German Center for Diabetes with Type 2 Diabetes Affect miRNA Expression in Smooth Muscle Research Cells MARCEL BLUMENSATT, PIA FAHLBUSCH, SABRINA GREULICH, BUJAR MAX- & 484-P HERA, KONSTANTINOS SMIRIS, HEIDI MUELLER, DANIELLA HERZFELD DE Inhibition of Coronary Artery BK Channel Function by Angiotensin WIZA, MARGRIET OUWENS, Düsseldorf, Germany II Exacerbates Myocardial Ischemia-Reperfusion Injury in Diabetic Perivascular adipose tissue (PVAT) is a visceral fat depot surrounding Mice the blood vessels in a way that no fascial layer separates this fat depot TONG LU, XIAO-LI WANG, HON-CHI LEE, Rochester, MN from the vascular wall. Factors secreted from PVAT can directly affect the Diabetes mellitus is an independent risk factor of vascular disease and function of the vasculature. Therefore we hypothesize that secreted factors cardiovascular mortality. We have previously reported that the large- from PVAT participate in the development of cardiovascular complications in conductance calcium-activated K+ (BK) channels and angiotensin II (Ang patients with type 2 diabetes (T2D) by the induction of proliferative and pro- atherogenic alterations in smooth muscle cells (SMCs). Here, we examined II) type 1 receptors (AT1R) are co-localized in the caveolae of coronary arterial smooth muscle cells (SMCs), forming a channel-receptor- whether conditioned media (CM) from PVAT from patients with type 2 caveolae complex that facilitates the inhibition of vascular BK channel diabetes (CM-PVAT-T2D) induce proliferation of SMCs and whether this can activity by Ang II. However, the pathophysiological consequence of BK be ascribed to alterations in miRNA expression in primary rat aortic SMCs. channel caveolae compartmentation in disease states such as diabetes SMCs were incubated with CM generated from PVAT-biopsies collected from mellitus, is unknown. In this study, we determined the role of vascular BK patients with T2D and without diabetes (ND) undergoing open heart surgery channels in myocardial infarction in streptozotocin (STZ)-induced diabetic whereafter proliferation of SMCs was measured by BrdU incorporation and mice. We found that coronary BK current density was markedly reduced expression levels of 343 rat miRNA species were quantifi ed by real-time by 87% in diabetic wild type (wt) mice, but was preserved in diabetic PCR. SMCs exposed to CM-PVAT-T2D showed a 1.8-fold increase in the rate caveolin-1 (Cav-1) knockout (KO) mice. BK channel α subunits, but not BK of BrdU-incorporation as compared to cells exposed to CM-PVAT-ND (Both P<0.01). Moreover, SMCs were found to express 228 miRNA species. Of these, channel β1 subunits, were found in the caveolae of coronary SMCs. Ang II suppressed 66% of coronary BK currents in non-diabetic wt mice, but miR-130b, miR-217, miR-423, miR-361, miR-183, miR-448, and miR-20b* were had no effect in Cav-1 KO mice. Ischemia/reperfusion (I/R) injury studies selectively up-regulated in cells exposed to CM-PVAT-T2D compared to CM- in Langendorff mouse heart preparations showed that diabetic wt mice PVAT-ND. In addition, miRNA-miR-185 was signifi cantly down-regulated by had myocardial infarct size twice as large as those of non-diabetic mice. CM-PVAT-T2D versus CM-PVAT-ND. Of these, elevated levels of miR-423 However, the I/R-induced infarct size was signifi cantly reduced in diabetic are associated with an increased proliferation. Functional analysis of the Cav-1 KO mice. Infarct size was enlarged by pretreatment with Ang II, but additional deregulated miRNAs will highlight their contributions to the CM-induced effects on SMC-function. Collectively, these data suggest attenuated by Losartan (an AT1R blocker) and by NS1619 (a BK channel activator). Pretreatment with iberiotoxin (a specifi c BK channel blocker) that alterations in miRNA expression in smooth muscle cells induced by worsened myocardial infarct size, which was not attenuated by NS1619. factors secreted from perivascular adipose tissue could contribute to the These results demonstrate that vascular BK channel activation protects pathogenesis of diabetes-related cardiovascular complications.

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A126 COMPLICATIONS—MACROVASCULAR—CELLULAR MECHANISMS OF ATHEROGENESIS IN DIABETES

& 487-P & 489-P Regulation of Vascular Smooth Muscle Cell Dysfunction by Diabetes- Palmitate-stimulated Monocytes Induce ICAM-1 and E-selectin induced MicroRNAs Expres sion in Vascular Endothelial Cells via an IL-1-Dependent MARPADGA A. REDDY, ZHUO CHEN, WEN JIN, SADHAN DAS, MEI WANG, Pathway LINDA LANTING, RAMA NATARAJAN, Duarte, CA YOSUKE SHIKAMA, NANAKO AKI, AKIKO HATA, MIHO NISHIMURA, MAKOTO We hypothesized that dysregulation of signaling networks by diabetes FUNAKI, Tokushima, Japan induced microRNAs (miRNAs) plays an important role in enhanced Increased intake of saturated fatty acid (SFA), such as palmiate, has been POSTERS

infl ammatory and growth responses of vascular smooth muscle cells linked to a higher risk of t ype 2 diabetes (T2D) and cardiovascular diseases (CVDs). Complications

(VSMC). We profi led miRNA expression using high throughput small RNA- It has also been known that the interleukin-1β (IL-1β)/IL-1 receptor antagonist Acute and Chronic seq in VSMC from type 2 diabetic db/db mice and control db/+ mice. Results (IL-1Ra) ratio in the blood plays a crucial role in regulating the expression level showed that 133 miRNAs were differentially expressed in db/dbVSMC of adhesion molecules, such as ICAM-1 and E-selectin, in vascular endothelial relative to db/+. We validated the differential expression of several of these cells. Monocytes are one of the major cells that secrete both IL-1β and IL-1Ra. miRNAs by RT-qPCR. To evaluate the role of diabetes regulated miRNAs, Although previous studies demonstrated that palmitate induces IL-1β secretion we further characterized the function of miR-504 because it was one of the in monocytes, little is known about the effect of palmitate on IL-1Ra secretion most highly induced miRNAs in db/dbVSMC, and its functions in VSMC or in monocytes, and the impact of secretions induced by palmitate-stimulated diabetes are unknown. We validated increased expression of miR-504 and monocytes on adhesion molecule expression in vascular endothelial cells. its host gene Fgf13 in db/dbVSMC. Bioinformatics analysis revealed that In this study, we provide evidence that SFAs increased IL-1β secretion and target genes of miR-504 can regulate cellular growth and infl ammation, and decreased IL-1Ra secretion in human monocytes. Unsaturated fatty acids dose- are associated with cardiovascular and metabolic diseases. Parallel RNA- dependently inhibited increased IL-1β secretion and decreased IL-1Ra secretion seq of the same cells showed downregulation of many of these miR-504 induced by palmitate. Moreover, in human aortic and vein endothelial cells, targets in db/dbVSMC, including Grb10, a key regulator of growth factor ICAM-1 and E-selectin expression was induced by treating with conditioned signaling, and Egr2, a transcription factor. Transfection of db/+VSMC with medium collected from palmitate-stimulated monocytes, but not with palmitate miR-504 mimics signifi cantly downregulated Grb10 and Egr2 and inhibited itself. Interestingly, up-regulation of adhesion molecules in endothelial cells by the activity of luciferase reporters containing their 3’-UTRs, verifying them the conditioned medium was completely abolished by IL-1Ra supplementation. as direct miR-504 targets. Interestingly, miR-504 overexpression, or gene These data suggest that palmitate-induced increase in the ratio of IL-1β/IL- silencing of Grb10, enhanced growth factor induced ERK activation and 1Ra secretion in monocytes may be involved in attachment of leucocytes on decreased Egr2 expression. Furthermore, Grb10 and Egr2 gene silencing with vascular endothelial cells, and IL-1β neutralization through receptor antagonism siRNAs increased expression of infl ammatory genes. These new results may be useful for preventing the onset of CVDs. demonstrate that miR-504 and its targets modulate growth factor signaling and promote VSMC infl ammation and dysfunction implicated in diabetes & 490-P induced accelerated vascular complications. AMPK Mediates Glucose Transporter Translocation by Antithrombin Supported By: ADA (1-08-JF-42); NIH in the Ischemic Heart YINA MA, JINLI WANG, HUI YANG, ALIREZA REZAIE, JI LI, Buffalo, NY, St. Louis, & 488-P MO Diabetes Blunt the Compensatory Enhancement of SUMOylation Antithrombin (AT) is an endogenous protein that inactivates several Intensity of Sarcoplasmic Reticulum Calcium-transporting ATPase enzymes of the coagulation system. Beside its function as an anticoagulant, after Myocardial Infarction AT also showed cardioprotective response through its anti-infl ammatory JING YAO, XING-HUI SHAO, SI-YONG TENG, YONG-JIAN WU, Beijing, China function. AMP-activated protein kinase (AMPK) is an energy sensor Diabetes is an independent risk factor for heart failure and mortality after that regulates energy generation and also is known as an important myocardial infarction(MI). Sarcoplasmic Reticulum Calcium-transporting cardioprotective pathway during myocardial ischemia and reperfusion. ATPase(SERCA2a) plays a key role in mainteining cardiac funtion. It was The objectives of this study is to determine the signaling mechanisms recently reported that SUMOylation could elevate the activity and stability by which AT protects heart from ischemic injury. The cardioprotective of SERCA2a. activities of wild-type (WT) AT and its derivatives were conducted in an Diet-induced type 2 diabetic rats and controls were divided into suture acute ischemia/reperfusion (20 min/4 hours) injury model in which the left ligation induced MI groups or sham groups. Echocardiography and left anterior descending coronary artery (LAD) was occluded. Drugs were given ventricular pressure were measured to determine cardiac function. The 5 minutes before reperfusion. The results showed that AT activates AMPK expressions of SERCA2a, SUMO1 , Ubc9 and other enzymes of SUMOylation by its heparin binding domain in both in vivo and ex vivo conditions. After were evaluated. The intensity of SUMOylation of SERCA2a was estimated blocking AMPK activity with over-expression domain-negative AMPKalpha as well. In addition, we also test whether the SUMOylation intensity of subunits in the heart, the cardioprotective function of AT against ischemia SERCA2a can be regulated by different concentrations of glucose and insulin and reperfusion damage was abolished. Furthermore, the increased AMPK or oxygen deprivation in vitro. activity by AT signifi cantly inhibits infl ammatory c-Jun N-terminal protein Diabetes exacerbated diastolic and systolic dysfunction of myocardium kinase (JNK) pathway caused by myocardial ischemia and reperfusion. We after MI. The expression of Ubc9, the main enzyme of SUMOylation, and further demonstrated that AT as a cardiac AMPK agonist also modulates SUMOylation intensity of SERCA2a was enhanced in 1 week post-MI non- substrate metabolism by increasing glucose oxidation and inhibiting fatty diabetic rats, while oxygen deprivation did not enhanced SUMOylation acid oxidation during ischemia and reperfusion. Moreover, AT activated intensity of cardiomyocyte in vitro. This compensatory enhancement was AMPK phosphorylates TUG (Tether containing a UBX domain for GLUT4) attenuated in 4 weeks post-MI non-diabetic rats and almost completely to release GLUT4 to cell membrane augmenting ischemic glucose uptake. blunted in 1 or 4 weeks post-MI diabetic rats. Interestingly, glucose alone The present results suggest that AT’s cardioprotective function is mainly increased Ubc9 expression and the SUMOylation intensity of SERCA2a of through triggering cardiac AMPK signaling to attenuate JNK infl ammatory cardiomyocytes in vitro in a concentration-dependent manner; however, signaling pathways and to modulate substrate metabolism by shifting fatty with addition of insulin, glucose decreased Ubc9 and SUMOylation intensity acid oxidation to glucose oxidation during ischemia and reperfusion. in a concentration-dependent manner on the contrary. Additionally, Supported By: ADA (1-11-BS-92) overexpression of Ubc9 with lentivirus neutralized the decreasing of SUMOylation intensity caused by glucose and insulin in vitro. 491-P These observations provide evidence that Ubc9 and SUMOylation of High Coagulation Factor Levels and Low Protein C Levels Contribute SERCA2a is involved in diabetes-mediated exacerbation of left ventricular to Enhanced Thrombin Generation in Patients with Diabetes Who dysfunction after MI. Do Not Have Macrovascular Complications Supported By: Peking Union Medical College (2012-1002-30) EUN SOOK KIM, HYUN KYUNG KIM, IL SUNG NAM-GOONG, YOUNG IL KIM, Ulsan, Republic of Korea, Seoul, Republic of Korea Aims: A prothrombotic state characterized by activation of the coagulation system has been implicated in the pathogenesis of vascular complications in diabetes mellitus. Recently, a thrombin generation assay was introduced as a laboratory assessment of global hemostatic potential. We used this

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A127 COMPLICATIONS—MACROVASCULAR—CELLULAR MECHANISMS OF ATHEROGENESIS IN DIABETES

thrombin generation assay to investigate global hemostatic potential in patients with diabetes who did not have macrovascular complications. Methods: This study was a prospective case-control study comparing 89 patients with diabetes with 49 healthy controls. The thrombin generation assay was conducted with the calibrated automated thrombogram using tissue factor with or without the addition of thrombomodulin, giving values for lag time, endogenous thrombin potential, and peak thrombin. Results: Patients with diabetes showed hypercoagulability, as detected POSTERS

Complications by the thrombin generation assay, compared with healthy controls.

Acute and Chronic Correspondingly, high levels of coagulation factors (II, V, VII, VIII, and X) and low levels of anticoagulant (protein C) were major contributing 494-P factors in this hypercoagulability. Interestingly, a high blood glucose level Insulin-like Growth Factor Binding Protein-1 Enhances Vascular was correlated with shortened clotting time, refl ecting the association Endothelial Regeneration in the Setting of Insulin Resistance between hyperglycemia and hypercoagulability. Patients who were taking AMIR AZIZ, NADIRA YULDASHEVA, JESSICA SMITH, PAUL CORDELL, NATALIE statins or angiotensin receptor blockers showed decreased endogenous HAYWOOD, RIC CUBBON, MARK KEARNEY, KAREN PORTER, STEPHEN thrombin potential ratio and increased protein C levels, suggesting WHEATCROFT, Leeds, United Kingdom relative hypocoagulability. Conclusions: Patients with diabetes showed Background: Insulin resistance is associated with endothelial cell (EC) hypercoagulability, high levels of coagulation factors, and low levels of dysfunction and impaired endothelial regeneration. We previously showed protein C. Further study is required to investigate how this hemostatic that IGFBP-1 enhances insulin sensitivity and stimulates nitric oxide potential may be used to guide physicians toward more effective production. Here we examine whether IGFBP-1 can enhance endothelial management of hemostatic complications. regeneration in insulin resistance. Methods: Endothelial regeneration was quantifi ed fi ve days after femoral 492-P artery wire-injury in insulin receptor (IR)+/- mice expressing human IGFBP-1. Evaluation of and Change in Endothelial Function with Glycemic The abundance and functional properties of angiogenic progenitor cells Control in Uncontrolled Type 2 Diabetes Mellitus were assessed. Endothelial regeneration was also quantifi ed ex vivo in OWAIS M. MASKATI, HETAL G. PATEL, NIBHA N. JAIN, NIVEDITA C. MEHTA, endothelium-denuded human saphenous vein seeded with human ECs pre- Ahmedabad, India, Vadodara, India incubated +/- IGFBP-1. Effects of IGFBP-1 on EC migration and proliferation Endothelial dysfunction detects otherwise silent increased atherosclerotic, were studied in vitro. macrovascular complication vis-a-vis cardiovascular risk. In this prospective Results: Endothelial regeneration was enhanced following wire injury and comparative study we examined 30 uncontrolled type 2 diabetes mellitus in IR+/- mice expressing IGFBP-1 compared to IR+/-controls (54% v 47%; patients with follow up after 12 weeks and 30 comparable healthy control P<0.05). This was not explained by altered abundance or function of APCs. subjects with an aim to compare the endothelial function. At baseline and 12 Incubation with IGFBP-1 signifi cantly enhanced the ability of human EC to weeks, fl ow mediated (FMD) and glyceryl trinitrate-mediated dilation (GTN) adhere to and regenerate denuded human vein ex vivo (110 v 71 {cells/high were determined, alongwith Waist hip ratio (WHR), fasting lipid profi le and powered fi eld}; P<0.01). TNF-α signifi cantly inhibited EC migration (164 v 252 presence of diabetic retinopathy (DR) at baseline, of diabetics and healthy {No. of migrated cells per mm of wound width}; P<0.01) and proliferation subjects. FMD during uncontrolled state (HbA1c 10.45±0.9) was 4.14±2.4 at (63% v 100%; P<0.01) in vitro. Co-incubation with IGFBP-1 restored the baseline which improved to 11.68±0.85 at 12 weeks with diabetes control migratory (199 v 164 {No. of migrated cells per mm of wound width}; P<0.05) (HbA1c 6.6±0.6), p<0.00001. Thus endothelial function improve in parallel and proliferative (78% v 63%; P<0.05) capacity of EC to control levels. with the glycemic control, strengthened by the fact that FMD in the fair Conclusions: IGFBP-1 over-expression improves defective endothelial control group (HbA1c 8.7±2.9) at the baseline was 8.57±0.29 indicating it repair in insulin resistant mice. Enhancement of EC migration, proliferation was already better as compared to poor control group (HbA1c 10.45±0.9). and adhesion may contribute to the favourable infl uence of IGFBP-1 on These fi ndings also resonated in the endothelial independent function vascular repair. Our fi ndings raise the possibility that manipulating IGFBP-1 represented by GTN, where at baseline in uncontrolled state (HbA1c could be a strategy to enhance endothelial repair in patients with insulin 10.45±0.9) it was 8.6±1.85 which improved to 15.02±1.68 at 12 weeks with resistance. diabetes control (HbA1c 6.6±0.6), p<0.00001. Only the male subgroup in Supported By: BHF diabetic group, showed highly signifi cant difference in the FMD between the subgroups of WHR (WHR ≤ 1.0: 7.34±2.12 vs. WHR >1: 3.08±0.98, p<0.0001), 495-P rest subgroups were statistically insignifi cant. Only high LDL cholesterol Regulation of Endothelial Function by Mammalian Diaphanous 1 showed impaired FMD (LDL ≤100: 7.47±2.41 vs. LDL>100: 4.09±2.46, DAIJI KAWANAMI, KEIICHIRO MATOBA, MSAMI TSUKAMOTO, SHO ISHIZAWA, p<0.01), rest dyslipidemia showed no statistical difference. Presence of DR YASUSHI KANAZAWA, JUN KINOSHITA, TAMOTSU YOKOTA, KAZUNORI was associated with impaired FMD (DR present: 3.51±2.06 vs. DR absent: UTSUNOMIYA, Tokyo, Japan 7.62±2.00, p<0.00001). FMD should be included in the risk stratifi cation, so The mammalian diaphanous-related formin (mDia) 1 and Rho-kinase that early intervention would reduce the burden of diabetic complication on are important effectors of small GTP-binding protein, Rho. We previously health care system on long term. reported that activation of Rho/Rho-kinase pathway is involved in the pathogenesis of atherosclerosis, however; the role of mDia1 in vascular cells 493-P still remains unknown. In this study, we aimed to investigate contribution of mDia1 to pro-infl ammatory gene expression in endothelial cells. When WITHDRAWN human umbilical vein endothelial cells (HUVECs) were exposed to LPA, a potent stimulant for Rho, activation of RhoA occurred, and gene expression of MCP-1 and PAI-1 was induced. Knockdown of mDia1 with siRNA inhibited these inductions, suggesting that mDia1 mediates LPA-induced expression of pro-infl ammatory cytokines. N-acetyl cysteine, an oxidative stress inhibitor, also attenuated LPA-induced expression of MCP-1, which indicates contribution of oxidative stress to MCP-1 induction. It is reported that mDia1 activates Rac1, an important regulator of redox signaling. We therefore examined the effect of mDia1 knockdown on Rac1 activation. Pull-down assay revealed that LPA induced signifi cant activation of Rac1 in endothelial cells. Knockdown of mDia1 with siRNA inhibited LPA-induced activation of Rac1 and subsequent induction of NOX1 (catalytic subunit of NADPH oxidase). We next mapped signaling events downstream of mDia1 driving MCP-1 production. LPA-induced expression of MCP-1 was inhibited by chemical inhibitors of p38MAPK, JNK, and NF-kB. Furthermore, siRNA- mediated mDia1 knockdown inhibited LPA-mediated phosphorylation of p38MAPK and JNK. LPA-induced p65 phosphorylation of NF-kB was also

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A128 COMPLICATIONS—MACROVASCULAR—CELLULAR MECHANISMS OF ATHEROGENESIS IN DIABETES inhibited by mDia1 knockdown. In conclusion, the present study indicates that 498-P mDia1 modulates expression of pro-infl ammatory cytokines in endothelial Liraglutide, a GLP-1 Receptor Agonist, Inhibits the Proliferation of cells in concert with activation of Rac1 which induces MCP-1 production via Vascular Smooth Muscle Cells by Activating Amp-activated Protein redox signaling molecules including p38MAPK, JNK, and NF-kB. mDia1 may Kinase and Altering Cell Cycles, and Retards Atherosclerosis in be a potential therapeutic target for atherosclerosis as well as Rho-kinase. Apo-e Defi cient Mice TERUO JOJIMA, TAKANORI TOMOTSUNE, KUNIHIRO SUZUKI, TOSHIE IIJIMA, 496-P KIKUO KASAI, YOSHIMASA ASO, Mibu, Japan

Osteocalcin Attenuates Atherosclerosis-induced Impairment of Several reports have demonstrated that both native GLP-1 and GLL-1 POSTERS Endothelial-dependent Relaxation through Akt/eNOS-dependent receptor agonists suppress the progression of atherosclerosis in animal Complications Pathway models of atherosclerosis. We investigated whether liraglutide, a GLP-1 Acute and Chronic JIANXIN DOU, HUATING LI, XIAOJING MA, MINGLIANG ZHANG, QICHEN FANG, analogue, can prevent the development of the atherosclerosis in apo- MEIYUN NIE, YUQIAN BAO, WEIPING JIA, Shanghai, China lipoprotein E knockout mouse (ApoE-/-) and examined the effectsof Recent studies have demonstrated a protective effect of osteocalcin liraglutide on the regulation of proliferation of vascular smooth muscle (OCN) on glucose homeostasis and metabolic syndrome. However, its role in cells (VSMCs) via enhancement of AMP-activated protein kinase vascular function remains unknown. This study investigated the contribution (AMPK) signals and alterations of cell cycle arrest in vitro. Treatment of OCN to the pathogenesis of endothelial dysfunction in the thoracic aorta with liraglutide increased the phosphorylation of AMPK in VSMCs and of apolipoprotein E-defi cient (ApoE-KO) mice. liraglutide-induced activation of AMPK was abolished by exendin 9-39, an Eight-week-old ApoE-KO mice were given chow or high fat diet (HFD) antagonist of GLP-1. Angiotensin (Ang) II-induced proliferation of VSMCs for 12 weeks with or without daily intraperitoneal injection of OCN. was suppressed by addition of liraglutide in a dose dependent manner. Intraperitoneal glucose tolerance test,insulin tolerance test,measurement In Ang II-stimulated VSMCs, cell cycles analysis using a fl ow cytometry of serum lipid profi les and blood pressure were carried out. Endothelium- showed that liraglutide reduced G2 phase, and Western blot analysis dependent relaxation (EDR) was measured by wire myography. Human demonstrated that liraglutide decreased the expression of cyclin D1 and umbilical vein endothelial cells (HUVECs) were used to study the role of OCN D2. In Apo-E-/- mice, treatment with liraglutide (400µg/day) retarded the on eNOS levels in vitro. PI3K inhibitor and Akt inhibitor V were used ex-vivo progression of atherosclerosis,being associated with the phosphorylation to determine whether PI3K/Akt/eNOS contributes to the benefi cial effect of of AMPK in VSMCs of aorta. These results suggested that liraglutide may OCN for the vascular or not. attenuate Ang II-induced VSMC proliferation via activating AMPK signaling It was found that daily injections of OCN can signifi cantly improve lipid and inhibiting cell cycle progression, resulting in retarding the progression metabolism, glucose tolerance and insulin sensitivity in ApoE-KO mice. In of atherosclerosis, independently of its glucose-lowering effect. ApoE-KO mice fed with high fat diet, the OCN-treated mice displayed an improved acetylcholine-stimulated EDR compared to the vehicle-treated 499-P group (Emax = 61.34 ± 5.64 vs. 42.30 ± 2.95%, p<0.01). In addition, compared Relation between HbA1c and 25-OH Vitamin D3 Levels to vehicle-treated HUVECs, OCN-treated HUVECs displayed increased SEBAHAT OZDEM, MUSTAFA K. BALCI, HASAN ALTUNBAS, SADI S. OZDEM, activation of the Akt-eNOS signaling pathway, as evidenced by signifi cantly Antalya, Turkey higher levels of phosphorylated Akt and eNOS. Furthermore, a similar There might be a relation between 25-OH Vitamin D3 (25-OHD3) and benefi cial effect of OCN on thoracic aorta was observed using ex vivo pancreatic functions since 25-OHD3 defi ciency was shown to be associated organ culture of isolated mouse aortic segment. However, this effect was with cardiovascular diseases in both type 2 diabetic patients and normal attenuated upon co-incubation with PI3K inhibitor or Akt inhibitor V. subjects. Besides that, severe 25-OHD3 defi ciency was associated with Our study demonstrated that OCN has an endothelial-protective effect in cardiovascular and all-cause mortality independently from the conventional atherosclerosis through mediating the PI3K/Akt/eNOS signaling pathway. risk factors in patients with type 2 diabetes mellitus. In the present study, Supported By: NSFC (81170788) we investigated the relation between HbA1c and 25-OHD3 levels in non- diabetic, pre-diabetic and diabetic patients. 497-P A total of 4679 subjects (3455 women, 1244 men, mean age: 56.3±16.1 Pro-infl ammatory Responses to Saturated Fatty Acids Are Different years) having simultaneous measurements of HbA1c (%) and 25-OHD3 (ng/ from Those Stimulated by Infectious Toll-like Receptor Agonists in ml) in our medical center between the dates of January 2013 - December Vascular Endothelial Cells 2013 were retrospectively included. Participants were stratifi ed into 3 groups HYUN-JU JANG, HAE-SUK KIM, JEONG-A KIM, Birmingham, AL as non-diabetic (HbA1c: < 5.70), pre-diabetic (HbA1c: 5.70-6.49) and diabetic Obesity is associated with a chronic infl ammatory status that accompanies (HbA1c: ≥ 6.50). Serum 25-OHD3 levels and whole blood HbA1c levels were elevated circulating saturated fatty acids (SFA). SFAs stimulate toll-like measured with the methods of ECLIA (Roche Diagnostics) and Tina-quant receptors (TLR), which induce pro-infl ammatory responses that contribute to 2nd generation assay (Roche Diagnostics), respectively. Relations between insulin resistance. Consistent with this physiology, TLR2 or TLR4 knock-out HbA1c and 25-OHD3 levels were measured using Pearson correlation. mice models are protected from obesity-induced pro-infl ammatory responses HbA1c and 25-OHD3 levels were 5.30 ± 0.29% and 24.79 ± 15.24 ng/ml in as well as insulin resistance. Although TLRs play important roles in SFA- non-diabetic, 6.03 ± 0.22% and 23.71 ± 14.17 ng/ml in pre-diabetic, 8.16 ± induced insulin resistance, the mechanisms underlying SFA-stimulated TLR 1.57% and 21.04 ± 12.84 mg/dl in diabetic groups. 25-OHD3 levels of both activation are not completely understood. In this study, we demonstrate pre-diabetic (p=0.036) and diabetic (p<0.0001) groups were signifi cantly that the mechanisms for pro-infl ammatory responses stimulated by SFA are lower than those of non-diabetic group. HbA1c levels correlated negatively different from those stimulated by lipopolysaccharide (LPS, TLR4 agonist) with 25-OHD3 levels in pre-diabetic (r= -0.060, p=0.029) and diabetic (r= or Pam3Csk4 (TLR2 agonist). Specifi cally, the kinetics of pro-infl ammatory -0.171, p<0.0001) but not in non-diabetic group. responses stimulated by SFA, including expression of cell adhesion molecule, The fi ndings of signifi cant decrements in 25-OHD3 levels together with E-selectin, and phosphorylation of Jun N terminus kinase (JNK) and NF-κB are signifi cant negative correlations with HbA1c levels both in pre-diabetic and different from those stimulated by LPS or Pam3Csk4. Inhibition of long chain diabetic subjects further emphasized the importance of 25-OHD3 levels in acyl-CoA synthetases (ACSL) by using triacsin C blunted SFA-, but not LPS- the course and the complications of diabetes. or Pam3Csk-stimulated pro-infl ammatory responses, while knock-down of individual ACSL failed to reduce SFA-stimulated infl ammation. Furthermore, 500-P pretreatment with triacsin C restored the ability of vasodilator actions of Pyruvate Dehydrogenase Kinase 4 Promotes Vascular Calcifi cation insulin that were impaired by palmitate. Interestingly, when expression of JUN-HWA HONG, AH-RHEM KANG, SUN-JOO LEE, BO-YOON PARK, YOUNGHOON high mobility group box 1 (HMGB1, an endogenous TLR agonist) was reduced, GO, HYEON-JI KANG, SEUNG HEE CHOI, CHAE-MYEONG HA, KEUN-GYU PARK, SFA-, but not LPS- or Pam3Csk4-stimulated infl ammatory responses were JUNG-GUK KIM, IN-KYU LEE, SUNG-RAE CHO, NAM HO JEOUNG, ROBERT A. reduced. Moreover, treatment with triacsin C inhibited SFA-, but not LPS- or HARRIS, Daegu, Republic of Korea, Changwon, Republic of Korea, Indianapolis, IN Pam3Csk4-stimulated secretion of HMGB1. From these results, we conclude Vascular medial calcifi cation is a well-established risk factor of cardio- that SFA stimulates pro-infl ammatory responses in vascular endothelium vascular events associated with diabetes, renal failure. It is closely linked through a HMGB1-mediated mechanism that is distinct from LPS- or with vascular smooth muscle cells (VSMCs), where pro-calcifi c stimuli Pam3Csk4-stimulated responses. such as inorganic phosphate, reactive oxygen stress, and high level of Supported By: ADA (1-12-BS-99); AHA (13GRNT17220057) vitamin D3 induce up-regulation of several osteochondrogenic markers, triggering osteogenic switch. We observed that expression of pyruvate

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A129 COMPLICATIONS—MACROVASCULAR—CELLULAR MECHANISMS OF ATHEROGENESIS IN DIABETES

dehydrogenase kinase 4 (PDK4), a mitochondrial protein to regulate of Overexpression of SHP-1 in VSMC inhibited insulin and PDGF induction of glucose oxidation, was increased in human VSMCs cultured mineralization tyrosine phosphorylation of their respective receptors, p-Erk (MAPK) activity medium. Therefore, we assessed whether inhibition of PDK4 could decrease as well as decreased migration and proliferation (all p<0.05). Transgenic vascular calcifi cation and ivestigated the molecular mechanism in detail. We mice overexpressing SHP-1 targeted selectively to VSMC using SMA22 examined the mineralization induced by Pi in vitro using von Kossa staining promoter increased SHP-1 expression in the aorta and VSMC by 2-fold. and quantitative analysis of calcium in VSMCs and isolated aorta. Vitamin Intimal hyperplasia in the femoral artery induced by wire injury decreased D was injected to PDK4 defi cient mice for inducing vascular calcifi cation by 52% in SHP-1 Tg mice vs. wild type (WT) controls on normal chow. Even on in vivo. PDK4 overexpression by using PDK4 containing adenoviral vector, high fat diet (60% fat) with induction of insulin resistance, hyperlipidemia, POSTERS

Complications even without BMP2 pre-treatment, increased vascular calcifi cation. PDK4 hyperinsulinemia and hyperglycemia, intimal hyperplasia in the femoral

Acute and Chronic defi cient mice showed profound attenuation of aortic calcifi cation induced ar ter y of SHP-1 Tg mice were reduced by 55% vs. WT mice. Furthermore, p-Erk by Vitamin D in vivo. The VSMCs cultured from PDK4 defi cient mice also activity decreased in SHP-1 Tg mice vs. WT mice in response to wire injury. presented an attenuation of mineralization and mRNA expression of Thus, these studies have identifi ed that SHP-1 expression is paradoxically osteogenic markers. Furthermore, DCA, known as PDK inhibitor, attenuated decreased due to oxLDL in VSMC of hyperlipidemic and diabetic rodents the mineralization of VMSCs and aorta cultured in Pi-treated medium. We leading to increased migration and proliferation of VSMC. These fi n d i n g s found that phosphorylation of SMAD1/5/8 by PDK4 induced osteogenic have identifi ed SHP-1 as a novel target for intervention in the treatment of differentiation of VSMCs by enhancing BMP2 signaling. PDK4 also induced cardiovascular diseases in diabetic and insulin resistant states. ROS generation, mitochondrial dysfunction, and apoptosis of VSMC. Supported By: JDRF However, despite the role of PDK4 in calcifi cation, normal bone remodeling was unaffected by PDK4 defi ciency. In this study, we showed that PDK4 503-P augmented osteogenic switch of VSMCs and vascular calcifi cation through Prevention by Novel Curcumin Analog C66 of Diabetic Cardio- the direct phosphorylation of SMAD1/5/8 and vascular calcifi cation may be myopathy Is Mediated by Inhibition of JNK, Accompanied with a treatable with compounds that inhibit PDK4. Preservation of Cardiac MT and Upregulation of Nrf2 YONGGANG WANG, SHANSHAN ZHOU, JIAN SUN, LU CAI, Changchun, China, 501-P Louisville, KY Demonstration of Insulin’s Critical Role in Angioblasts Formation and The development of diabetic cardiomyopathy (DCM) is attributed to Revascularization in Wound Healing With and Without Diabetes oxidative stress, which may be related to JNK activation. Here we tested SAYAKA KATAGIRI, YASUTAKA MAEDA, KYOUNGMIN PARK, QIAN LI, MOGHER a hypothesis whether curcumin analog C66 as a potent antioxidant can KHAMAISI, LUCA LANCEROTTO, DENNIS P. ORGILL, GEORGE L. KING, Boston, MA protect diabetes-induced cardiac functional and pathogenic changes Defective angiogenesis is associated with poor wound healing in via inhibition of JNK function. Diabetic mice were induced with a single diabetes. Since insulin can promote angiogenesis in response to ischemia, intraperitoneal injection of streptozotocin. Diabetic and age-matched via the expression of vascular endothelial growth factor (VEGF), we proposed control mice were divided into three groups, each group treated with C66, that enhancing insulin action on the endothelial cell (EC) may improve c-Jun N-terminal kinase inhibitor (JNKi, sp600125) or vehicle (1% CMC-Na wound healing. To test this hypothesis, insulin action was enhanced by solution) by gavage, at 5mg/kg, every other day for three months. Neither overexpressing IRS-1 (intracellular messenger of insulin receptors, IR) to the C66 nor JNKi impacted diabetic hyperglycemia and body-weight gain, endothelium using the VE-cadherin promoter (ECIRS1 mouse. The expression but both signifi cantly prevented diabetes-induced JNK phosphorylation of IRS1 was increased by 2.7 fold in the EC but not in other vascular cells or in the heart. Compared with basal line, cardiac function was signifi cantly fi broblasts. ECIRS1 mice had similar systemic glucose tolerance and insulin decreased in diabetic mice at 3 months of diabetes, but not in C66- and sensitivity as wild type, WT, mice, but insulin’s activation of eNOS in EC was JNKi-treated mice. Cardiac fi brosis, oxidative damage, ER stress, and cell enhanced by 2.5 fold. Re-perfusion, VEGF expression and capillary density apoptosis were also signifi cantly increased in diabetic mice, all which were were signifi cantly increased by 50% in hindlimb after femoral artery ligation prevented by C66 or JNKi treatment under diabetic conditions. Both C66 and in the ECIRS1 mice vs. WT. Wound healing was assessed by comparing JNKi preserved metallothionein (MT) expression nearly to control level in the open wound (OW), contraction (C) and epithelialization (E) ratios of full diabetic conditions, which was signifi cantly depressed in diabetic heart; and thickness dorsal wounds on ECIRS1 and WT mice over 14 days. Improvements signifi cantly increased Nrf2 expression and its downstream gene expression in OW and E ratios were signifi cant (p< 0.05) at 3 and 7days. High fat diet in normal and diabetic conditions. These results suggest that like JNKi, C66 (HFD) induced obesity, insulin resistance and diabetes in both ECIRS1 and WT is able to prevent diabetic up-regulation of JNK function, resulting in a mice; however only WT, and not ECIRS1, mice on HFD exhibited signifi cant prevention of diabetes-induced cardiac fi brosis, oxidative stress, ER stress, retardation of OW and E ratios. Insulin signaling in the wound granulation and cell death, along with a preservation of cardiac MT expression and up- tissues from ECIRS1 showed enhanced activation of pAkt and expressions regulation of Nrf2 expression and function. of VEGF, Flk1 and VE-cadherin vs. WT mice. Interestingly, the contents of angioblasts (CD45(-)Flk1(+)CD31(-)) and EC (CD45(-)Flk1(+)CD31(+)) in the 504-P wound granulation tissues from ECIRS1 mice were signifi cantly increased (>75%) as assessed by immunohistology and fl ow cytometry of isolated cells vs. WT mice. These fi ndings demonstrated that insulin can regulate WITHDRAWN the development of angioblasts and progression to EC, which are critical for improving wound healing in diabetes and obesity. Supported By: Sunstar Foundation

502-P Downregulation of SHP-1 by Lipids: A Novel Mechanism to Accelerate Smooth Muscle Cell Proliferation and Intimal Hyper- plasia in Diabetes WEIER QI, QIAN LI, CHONG WEE LIEW, KEVIN CROCE, GEORGE L. KING, Boston, MA, Chicago, IL Accelerated arterial intimal hyperplasia and restenosis are major cardiovascular pathologies observed in diabetic patients. Hypermigration and proliferation of vascular smooth muscle cells (VSMC) are critical steps to induce arterial restenosis. We have observed that the expression of SHP- 1, a tyrosine phosphatase, was decreased by 42% and 70%, respectively in ZF and ZDF rats compared with their lean and nondiabetic controls (p<0.05). This fi nding in the artery is paradoxically different from the retina and glomeruli where diabetes and hyperglycemia increased the expression of SHP-1 leading to deactivation of PDGF receptors in the retina and VEGF receptors in glomerular podocytes. In VSMC, oxLDL and acLDL, but not high glucose (25mM), decreased SHP-1 mRNA and protein expressions (p<0.05).

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A130 COMPLICATIONS—MACROVASCULAR—CELLULAR MECHANISMS OF ATHEROGENESIS IN DIABETES

levels of the key cholesterol transporters ABCA1 and ABCG1 are signifi cantly lower in RAGE expressing vs. RAGE null diabetic BMDMs. These fi ndings were confi rmed in RAGE-silenced human macrophages (THP-1 cells) in high (25 mM) vs. basal (5.5 mM) glucose conditions. We thus hypothesized that RAGE downregulates ABCA1 and ABCG1 potentially via multiple mechanisms, including the action of AGEs. Our preliminary data with ABCG1 promoter deletion mutants using the fi refl y/renilla luciferase assay suggest that AGE-RAGE action on downregulation of ABCG1 promoter luciferase activity POSTERS

can be narrowed down to -304 to -413 within the promoter. Studies are Complications

underway to further probe the transcription factors binding to this specifi c Acute and Chronic region by electrophoretic mobility shift assays and ChIP assays to establish functionality. Taken together, AGE-RAGE downregulates cholesterol effl ux in diabetic BMDMs; the molecular mechanism by which RAGE regulates ABCG1 will defi ne novel gene regulatory roles for RAGE in diabetic atherosclerosis.

507-P Activation of Nrf2 by Sulforaphane via AKT/GSK-3β/Fyn Pathway Prevents Angiotensin-II-induced Cardiomyopathy YING XIN, JIANG XIN, YANG BAI, LU CAI, Louisville, KY, Changchun, China Angiotensin II (Ang II) has been considered as a key pathological factor for diabetic cardiomyopathy. Sulforaphane (SFN) is anti-oxidative supplement through activation of Nrf2 pathway. Here we examined whether SFN could 505-P protect from Ang II-induced cardiomyopathy and the underlying mechanism. High Glucose Upregulates ORAI and STIM Through Calcium- FVB mice were given subcutaneous injection of Ang II (0.5 mg/kg) for Calcineurin-NFAT Pathway 2 months with or without SFN treatment (0.5 mg/kg) for 3 months and NIKOLETA DASKOULIDOU, BO ZENG, LISA BERGLUND, GUI-LAN CHEN, OLGA then kept until 6 months. At 3 and 6 months, blood pressure and cardiac KOTOVA, MARIA F. GOMEZ, STEPHEN L. ATKIN, SHANG-ZHONG XU, Hull, United function were assessed. SFN signifi cantly prevented Ang II-induced cardiac Kingdom, Malmö, Sweden dysfunction at both 3 and 6 months. Ang II caused remarkable pathological ORAI and STIM genes are recently identifi ed store-operated Ca2+ channel changes, including myocardial hypertrophy and collagen accumulation, along molecules that play important roles in human physiology and pathology. with increases in cardiac oxidative damage (3-NT and 4-HNE), infl ammation The effects of high glucose (25 mM D-glucose) on the expression of ORAI (TNF-α and PAI-1), and fi brotic response (TGF-β1 and CTGF). Those damages and STIM, Ca2+ infl ux, ORAI channel activity and potential underlying were almost completely prevented by 3-month SFN treatment that up- mechanisms were investigated using cell models and in vivo tissue samples regulated Nrf2 function, refl ected by increased Nrf2 phosphorylation and from diabetic patients and mice. downstream antioxidants. To defi ne the direct role of SFN-activated Nrf2 ORAI1-3 and STIM1-2 were detected in vascular endothelial and smooth in preventing Ang II-induced cardiomyopathy, in vitro H9c2 cells were muscle cells using RT-PCR, Western blotting and immunostaining. Expression treated with Ang II in the absence or presence of Nrf2 siRNA to silence Nrf2 of ORAI1-3 and STIM1-2 was upregulated by chronic treatment with high expression. SFN signifi cantly up-regulated Nrf2 and also prevented Ang glucose in cell models. The upregulation was also observed in human aortae II-induced CTGF and PAI-1expression, which were completely abolished by from Type 2 diabetic patients and kidney tissues from streptozotocin-induced Nrf2 silence. Furthermore, cardiac-overexpressing Nrf2 gene (Nrf2-TG) and and Akita Type 1 diabetic mouse models. The high glucose-induced gene wild-type (WT) mice were treated with Ang II (0.5 mg/kg) for 2 months. Ang upregulation was prevented by the calcineurin inhibitor cyclosporin A, the II-induced cardiomyopathy was seen in WT mice, but not in Nrf2-TG mice. For store-operated channel blockers diethylstilbestrol and BTP-2 and by gene mechanistic study, H9c2 cells were given SFN (10 µM) simultaneously with 2+ silencing of NFATc3. H2O2 also upregulated ORAI1-3 and STIM1-2. Ca infl ux, and without Akt inhibitor. SFN’s activation of Nrf2 was partially inhibited ORAI1-3 channel activity and STIM1 movement were investigated using by Akt inhibition that also induced GSK-3β activation and Fyn nuclear Ca2+ imaging, whole-cell patch clamp and live-cell fl uorescence imaging. accumulation. These results suggest that Ang II-induced cardiomyopathy Chronic treatment with high glucose enhanced store-operated Ca2+ infl ux in can be prevented by SFN via Akt/GSK-3β/Fyn-mediated activation of Nrf2 endothelial cells. Nevertheless, no direct effect of high glucose on ORAI1- antioxidant pathway. 3 currents and cytosolic STIM1 movement and clustering after Ca2+ store- Supported By: ADA (1-11-BS-17); NSFC (81201218) depletion was observed in the cells overexpressing STIM1/ORAI1-3. It is concluded that store-operated Ca2+ entry is enhanced by high glucose 2+ 508-P via upregulation of ORAI and STIM expression through Ca -calcineurin- P53 Silenced, Apoptosis Resistant, Endothelial Progenitor Stem NFAT pathway. Thus, STIMs and ORAIs are new target proteins of oxidative Cells (EPC) Improve Collateral Circulation Post Femoral Artery stress, especially in diabetes, which may provide a novel concept for Occlusion 2+ the abnormality of Ca homeostasis in blood vessels from patients with SABYASACHI SEN, CYRIL CHOU, JOSEPH JERRY, Washington, DC, Springfi eld, MA, diabetes. Amherst, MA Literature shows that EPCs contribute to increased collateral vessel 506-P formation following vaso-occlusion. However diabetes is associated The Receptor for Advanced Glycation Endproducts (RAGE) Regu lates with poor collateral vessel formation. We cultured human EPCs (defi ned Cholesterol Effl ux via AGE-mediated Modulation of Cholesterol as CD34+ cells) and exposed them to 5.5 mM (normal glucose, NG) and Trans porters in Diabetic Atherosclerosis 20mM (high glucose, HG) glucose which caused signifi cant EPC apoptosis GURDIP DAFFU, XIAOPING SHEN, ROSA ROSARIO, RAVICHANDRAN RAMASAMY, within 48hrs. This fi nding was ssociated with up-regulation of P53 and its ANN MARIE SCHMIDT, New York, NY downstream genes such as P21, PUMA and Caspase-3. We hypothesized Atherosclerosis development is signifi cantly accelerated in patients with that EPC apoptosis in hyperglycemia is secondary to up-regulation of P53 type 1 or 2 diabetes. A relative dearth of diabetes-specifi c cardiovascular and silencing P53 may help neo-vascularization. We obtained mouse EPCs therapies exists, indicating new therapeutic targets are needed. In human from P53 KO mice and observed that p53 null EPCs are apoptosis resistant to subjects, HDL’s (high density lipoprotein) ability to promote cholesterol death in HG while retaining the important endothelial properties. Next, we effl ux from macrophages is inversely correlated with surrogate markers of used Lenti and Adenovirus to silence P53 in human EPCs (hEPCs). P53 silenced atherosclerosis. In human diabetic subjects, reverse cholesterol transport hEPC showed better survival in HG. We developed unilateral femoral artery is reduced. The Receptor for Advanced Glycation Endproducts (RAGE) has occlusion model to mimic peripheral vascular disease (PVD)in streptozotocin been shown to play a key role in diabetic atherosclerosis. We addressed the induced type 1 diabetic or Leptin resistant type 2 diabetic mouse model. hypothesis that RAGE contributed to accelerated diabetic atherosclerosis We delivered saline, P53 WT and P53 null mEPCs intra-muscularly around via impaired macrophage cholesterol effl ux. Our data reveal the novel the femoral occlusion (n=7 in each group) and counted number of capillaries. fi nding that RAGE suppresses cholesterol effl ux in bone marrow-derived We also quantifi ed tissue perfusion by laser doppler of the surgical and macrophages (BMDMs) retrieved from type 1 diabetic mice and that mRNA non-surgical limbs at days 3, 7, 9 and 14, post EPC transplantation. we

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A131 COMPLICATIONS—NEPHROPATHY—BASIC AND EXPERIMENTAL SCIENCE

also conducted qRT-PCR and western blot of key endothelial genes such of microRNA29s in diabetic mice; linagliptin restored microRNA29s. TGF- as eNOS, p-eNOS, VEGF-A, PECAM-1 and vWF from both quadriceps in all β2-induced DPP-4-3’UTR reporter activity was suppressed microRNA29 groups of mice. Results: The group that received P53null EPCs had the most mimetics; inhibition of microRNA29s increased such reporter activity. favorable outcome. Preliminary results from transplantation of lenti p53 Using cultured endothelial cells, we found that linagliptin inhibited TGFβ2- silenced hEPCs also indicate increased vessel formation compared to non induced EndMT and such anti-EndMT effects of linagliptin were mediated p53 silenced hEPCs in NOD-SCID diabetic mice. Summary: Transplantation through microRNA29s induction. These results indicate the possible novel of P53 null EPCs in presence of hyperglycemia help improve collateral vessel pleiotropic action of linagliptin to restore normal kidney function in diabetic formation in a PVD setting compared to WT-EPC group with signifi cant patients with renal impairment. POSTERS

Complications clinical implications. Acute and Chronic Supported By: AHA & 511-P DPP-4 Inhibition by Linagliptin Attenuates Filtration Barrier Injury 509-P and Oxidative Stress in the Zucker Obese Rat GQ Is a Novel Class of Safe, Anti-infl ammatory Insulin Sensitizers VINCENT DEMARCO, RAVI NISTALA, ANNAYYA AROOR, JAMES R. SOWERS, JOEY Z. LIU, CHRISTOPHER LYON, LAURIE MINZE, YUELAN REN, MARICELA JAVAD HABIBI, MELVIN R. HAYDEN, WILLIAM KNIGHT, TAMARA HANCOCK, REYES, TUO DENG, IVAN PITTA, DULCINEIA ABDALLA, FRANCISCO NEVES, PAUL THOMAS KLEIN, ADAM WHALEY-CONNELL, Columbia, MO, Biberach, Germany WEBB, WILLA HSUEH, Houston, TX, Recife, Brazil, São Paulo, Brazil Obesity-related glomerulopathy is characterized initially by glomerular A safe insulin-sensitizer is badly needed for treatment of type 2 diabetes. hyperfi ltration with hypertrophy and then development of proteinuria. We recently developed a novel ‘GQ’ class of peroxisome proliferator- Putative mechanisms include endothelial dysfunction and injury to the activated receptor-γ (PPARγ) ligands. These partial PPARγ agonists displayed fi ltration barrier due to oxidant stress and immune cell activation. There insulin-sensitizing, anti-infl ammatory and anti-atherosclerotic effects has been recent interest in targeting dipeptidyl peptidase (DPP)-4 to reduce similar to the full PPARγ agonist rosiglitazone (RSG) in middle-aged low oxidant stress and improve kidney injury. The role of DPP-4 in glomerular density lipoprotein receptor null (LDLR-/-) mice fed a high caloric, atherogenic function and progression of obesity-related glomerulopathy is not well Western diet. GQs directly stimulated a key antioxidant transcription factor, understood. We utilized a model of obesity-related glomerulopathy, the NF-E2-related factor 2 (Nrf2), and its transcriptional partners Mafg and Zucker Obese (ZO) rat (aged 8 weeks), fed a normal chow or chow containing Mafk in LPS-induced macrophages, while increasing multiple Nrf2-regulated the DPP-4 inhibitor linagliptin for 8 weeks (83 mg/kg chow, corresponding to antioxidant genes, including catalase, Ho-1, Nqo1 and Gsta2. GQ treatment 3 mg/kg). Compared with Zucker Lean (ZL) controls, there were increases in also suppressed LPS-induced reactive oxygen species production, pro- plasma DPP-4 activity and proteinuria in ZO rats. Hypertrophic remodeling, infl ammatory NFκB and Stat1 pathway activation, and IL-1α, IL-1β, IL-6, IL-12, marked by increases in glomerular size, podocyte hypertrophy and foot and MCP-1 cytokine expression in these cells, but this effect was lost in Nrf2- process effacement, was also evident in ZO rats. These fi ndings occurred in /- macrophages. Anti-atherosclerotic and insulin-sensitizing effects of GQs parallel with decreased expression of glomerular and distal tubular stromal- were also abrogated in LDLR-/- mice transplanted with Nrf2-/- bone marrow. derived factor (SDF)-1α and increased renal oxidative stress characterized Treatment of these mice with RSG, but not GQ, resulted in rapid mortality by increases in NADPH oxidase activity, reactive oxygen species (ROS) that was associated with cardiac hypertrophy and heart failure, increased production and 3-nitrotyrosine (3-NT) levels. Linagliptin decreased cardiac expression of cardiac stress and fi brosis genes, and reduced cardiac circulating and renal DPP-4 activity by 87 and 76% (p<0.01), respectively, in expression of cardiac rhythm-associated genes (Kcnn2, Kcnn5, Serca2, and concert with increased plasma active GLP-1 (3.9 ± 1.5 to 24.4 ± 3.8; p<0.001). Cx43). RSG-treated, but not GQ-treated, mice also revealed increased renal This was associated with reduced renal ROS level and 3-NT content, expression of sodium-retaining genes (Sgk1, Enac1a). Both phenotypes reduced proteinuria (from 16.1 ± 3.4 to 5.84 ± 1.2; P<0.01), increased nephrin correspond to known RSG sides effects. GQs thus: 1) display potent anti- and SDF-1α protein expression (39 and 54%, respectively) and improved infl ammatory activity, 2) inhibit accelerated atherosclerosis in an obese, glomerular and fi ltration barrier remodeling. In summary, these data support aging mouse model, 3) require Nrf2 expression for their anti-atherosclerotic, a pathological role for DPP-4 in glomerular fi ltration function and effi cacy of anti-infl ammatory, and insulin-sensitizing actions, and critically 4), do not the DPP-4 inhibitor, linagliptin in improving obesity-related glomerulopathy activate genes that promote RSG-induced toxicity. GQ ligands may thus and fi ltration barrier injury due to oxidant stress. represent novel therapeutics for the treatment of type 2 diabetes. Supported By: Boehringer Ingelheim

& 512-P COMPLICATIONS—NEPHROPATHY—BASIC AND SGLT2 Inhibitor Empaglifl ozin Increases Renal NHE3 Phosphoryla- EXPERIMENTAL SCIENCE tion in Diabetic Akita Mice: Possible Implications for the Prevention of Glomerular Hyperfi ltration YILING FU, MARIA GERASIMOVA, ERIC MAYOUX, TAKAHIRO MASUDA, VOLKER Guided Audio Tour: Complications—Nephropathy—Basic and Experi- VALLON, San Diego, CA, Biberach, Germany mental Science (Posters: 510-P to 515-P), see page 13. Inhibition of the Na glucose cotransporter SGLT2 lowers blood glucose and hyperfi ltration in diabetes. This is consistent with inhibition of SGLT2- & 510-P mediated glucose and Na reabsorption in the early proximal tubule and the Linagliptin-mediated DPP-4 Inhibition Ameliorates Kidney Fibrosis in tubular hypothesis of diabetic glomerular hyperfi ltration. Here we report Streptozotocin-induced Diabetic Mice via Restoring microRNA29s in metabolic cage studies in wild-type mice that the acute glucosuric KEIZO KANASAKI, MEGUMI KANASAKI, SEN SHI, SWAYAM P. SRIVASTAVA, response to the SGLT2 inhibitor empaglifl ozin (3 mg/kg by oral gavage) is DAISUKE KOYA, Kahoku, Japan associated with an increase in urinary anion gap (Na-K-Cl) vs. vehicle (by Kidney fi brosis is the fi nal common of all progressive chronic kidney 8.2±1.5 nmol/min/g bw; P<0.05), which may refl ect enhanced bicarbonate diseases, of which diabetic nephropathy is the leading cause. Endothelial-to- excretion. Application of empaglifl ozin for 10 days (300 mg/kg diet; ~30-35 mesenchymal transition (EndMT) has emerged as one of the most important mg/kg/d) modestly reduced blood pH (7.33±0.01 vs. 7.40±0.01), bicarbonate origins of matrix-producing fi broblasts. Dipeptidyl peptidase-4 (DPP-4) concentration (20.1±0.9 vs. 25.6±0.3 mEq/L), and base excess (-5.3±0.9 vs. inhibitors have been introduced into the market as anti-diabetic drugs. Here, 0.7±0.3 mEq/L)(n=5; all P<0.001). The Na-H-exchanger NHE3 contributes to we found that the DPP-4 inhibitor linagliptin ameliorated kidney fi brosis in proximal tubular bicarbonate reabsorption, and its phosphorylation at serines diabetic mice without altering their blood glucose levels associated with the 552 and 605 associates with reduced activity. Treatment of type I diabetic inhibition of EndMT and the restoration of microRNA29s. Streptozotocin- Akita mice with empaglifl ozin for 15 weeks enhanced renal expression of induced diabetic CD-1 mice exhibited kidney fi brosis and strong immuno- pS552-NHE3 and pS605-NHE3 by 73 and 76% (P<0.05), respectively, without reactivity for DPP-4 after 24 weeks on the onset of diabetes. At 20 weeks blunting the diabetes-induced increase in total renal NHE3. The studies after the onset of diabetes, mice were treated with linagliptin for 4 weeks. provide fi rst evidence for a link between SGLT2 inhibition and reduced NHE3 Linagliptin-treated diabetic mice exhibited a suppression of DPP-4 activity/ activity, which may further increase NaCl concentrations at the macula protein expression and an amelioration of kidney fi brosis associated with densa, thereby contributing to the prevention of glomerular hyperfi ltration the inhibition of EndMT. The therapeutic effects of linagliptin on diabetic by empaglifl ozin observed in the same set of diabetic mice. kidneys were associated with the suppression of profi brotic programs, as Supported By: NIH assessed by mRNA microarray analysis. We found that the induction of DPP- 4 observed in diabetic kidneys may be associated with suppressed levels

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A132 COMPLICATIONS—NEPHROPATHY—BASIC AND EXPERIMENTAL SCIENCE

DN-associated genes do not fully elucidate the mechanisms underlying the & 513-P progression of the disease. In this report, to provide an additional catalog Glyoxalase-1 Inhibition Leads to Podocyte Insulin Resistance and of functionally important candidate genes for DN, we performed a gene- Features Resembling Diabetic Kidney Disease expression based genome-wide association study (eGWAS): searching LINDA A. GALLO, MICHEAL S. WARD, BROOKE E. HARCOURT, AMELIA K. for genes repeatedly implicated in functional microarrays (often publicly- FOTHERINGHAM, DOMENICA A. MCCARTHY, SALLY A. PENFOLD, JOSEPHINE available). We meta-analyzed 67 DN case-control microarrays from glomeruli M. FORBES, Woolloongabba, Australia, Melbourne, Australia in human kidney biopsy samples (Figure), and identifi ed 429 signifi cantly up- The plasma concentration of the reactive carbonyl, methylglyoxal (MGO), regulated genes and 323 down-regulated genes in DN glomeruli (P < 2.2 6 POSTERS is elevated in diabetes. Increased accumulation of MGO may contribute × 10 ). Pathway analysis highlighted the extracellular matrix (ECM) and Complications to insulin resistance at peripheral sites of glucose uptake. A defi ciency in receptor interaction, natural killer cell mediated cytotoxicity, and toll-like Acute and Chronic podocyte insulin signalling impairs podocyte function resulting in kidney receptor signaling pathway (TLR1, TLR2 and MYD88) in up-regulated genes. disease. Glyoxalase-1 (GLO-1) is an enzyme considered to detoxify MGO. Gene Ontology term analysis revealed the enrichment of “regulation of Hence, we examined the effects of inhibiting GLO-1 on podocyte insulin epithelial cell proliferation” in down-regulated genes. We also found ERBB4 signalling and renal function under diabetic conditions. Human podocytes gene was signifi cantly down-regulated in patients with DN, together with were exposed to a GLO-1 inhibitor under normal and diabetic-like conditions. the other related genes in Erbb signaling pathway, such as CDKN1B, SOS2, Insulin sensitivity and glucose uptake were assessed using pAKT/AKT and PLCG2 and CAMK2G. Our studies have cataloged multiple gene-expression membranous GLUT4 protein expression. Male db/db mice (reminiscent of signatures that may play a role in the pathogenesis of DN or could serve as human type 2 diabetes) and db/m control mice were administered with a biomarkers. GLO-1 inhibitor on alternate days from weeks 6 to 9 of life (50mg/kg body weight) and renal function and glycaemic control were assessed. Human podocytes exposed to an inhibitor of GLO-1 showed reduced insulin signalling with lower pAKT/AKT ratios and GLUT4 membrane translocation. GLO-1 activity was reduced in kidney cortices of db/db mice and under GLO- 1 inhibition in both genotypes. At 9 weeks of age, plasma cystatin C was elevated in db/db and db/m mice administered with the GLO-1 inhibitor. However, peripheral insulin resistance was not affected with GLO-1 inhibition. Decreased insulin signalling and expression of GLUT4 in human podocytes exposed to an inhibitor of GLO-1 were consistent with the degree of renal dysfunction in diabetic mice. Alterations to the glyoxalase system in diabetes may contribute to renal impairment by adversely affecting 516-P podocyte insulin sensitivity. Evolution of Renal DPP-4 Expression in Mammals Supported By: NHMRC YULIYA SHARKOVSKA, CHRISTOPH REICHETZEDER, ROBERT KLOPFLEISCH, EDWARD GRACE, THOMAS KLEIN, BERTHOLD HOCHER, Berlin, Germany, Potsdam, & 514-P Germany, Biberach, Germany Genome-Wide Analysis of High Glucose-mediated Gene Regulation Dipeptidyl peptidase (DPP)-4 is a membrane-bound and soluble protease in Glomerular Mesangial Cells: Induction of Platelet Derived Growth expressed in a variety of tissues, and is involved in the degradation of various Factor-C via Carbohydrate Response Element Binding Protein in circulating peptides. Although DPP-4 shows strong expression in the kidney, Diabetic Kidney there is little known about the function of renal DPP-4. Current literature YUICHI MAKINO, HIROYA KITSUNAI, KATSUTOSHI MIZUMOTO, HIDEMITSU suggests that the expression patterns of DPP-4 in the nephron vary among SAKAGAMI, TSUYOSHI YANAGIMACHI, YUKIHIRO FUJITA, ATSUKO ABIKO, different species. We therefore analyzed using immunohistochemistry YUMI TAKIYAMA, MASAKAZU HANEDA, Asahikawa, Japan the expression of DPP-4 in kidneys from 7 different mammalian species. Gene regulation by high glucose is an important issue in molecular Paraffi nized kidney samples fi xed in 4% formaldehyde were obtained from patho-physiology of metabolic diseases including diabetes mellitus and its the Institute of Animal Pathology at Free University Berlin. Sections were cut complications. We previously reported that high glucose activates hypoxia- (3 µm) and immunohistochemically stained against DPP-4. Samples (n = 3-10) inducible factor-1α and downstream gene expression in mesangial cells, from 7 different species (mice, rats, cats, kangaroo, pigs, old/new world leading to an extracellular matrix expansion in diabetic glomeruli. A glucose monkeys and humans) were analyzed by two investigators for the presence responsive transcription factor carbohydrate response element binding of tubular and glomerular DPP-4 expression. Mice, rats, cats and kangaroos protein (ChREBP) is a key mediator for such perturbation of gene regulation uniformly showed both glomerular and tubular DPP-4 expression. In pigs, by high glucose. To provide more insight into glucose-mediated gene old /new world monkeys and humans, DPP-4 expression was only seen in regulation in mesangial cells, we performed chromatin immunoprecipitation renal tubuli and no expression was found in glomeruli. However, humans and with anti-ChREBP antibodies followed by DNA microarray analysis (ChIP- monkeys with chronic proteinuric kidney disease showed glomerular DPP-4 chip) and identifi ed platelet derived growth factor C (PDGF-C) as a novel expression. The results of this study suggest an evolution in the pattern target gene of ChREBP in mesangial cells. In the streptozotocin-induced of DPP-4 expression in the kidney. Renal DPP-4 appears to be expressed diabetic mouse model, glomerular mesangial cells had a signifi cant exclusively in tubular epithelial cells in species that are more closely related increase in PDGF-C expression along the disease course of diabetes. In to humans in terms of phylogenic and/or physiologic resemblance. If the cultured mesangial cells, high glucose enhanced expression of PDGF-C and kidney is diseased in higher mammals, there seems to be a shift towards knock-down of ChREBP abrogated such induction response. Upregulated ancient expression patterns. Incretin-based therapies which inhibit DPP-4 PDGF-C encouraged mesangial cells to produce type IV collagen and type activity may potentially elicit benefi cial effects on the glomerulus in disease VI collagen possibly via an autocrine mechanism and reduction of cellular settings such as diabetic nephropathy. PDGF-C compromised induction of those fi brotic extracellular matrixes by Supported By: Boehringer Ingelheim high glucose. Interestingly, urinary PDGF-C level in diabetic model mice was signifi cantly elevated in a similar fashion to urinary albumin. Taken together, 517-P we hypothesis that high glucose-mediated induction of PDGF-C via ChREBP How Can Birds Live with Chronic Hyperglycemia without Experienc- in mesangial cells contributes to the extracellular matrix deposition in ing Diabetic Complications? Is the Apparent Absence of an Avian diabetic glomerulopathy, which may provide a platform for novel diagnostic Rage Gene a Factor? and therapeutic strategies for diabetic nephropathy. BENJAMIN S. SZWERGOLD, CRAIG B. MILLER, West Lebanon, NH, Teaneck, NJ Normal glucose levels in blood plasma of all birds are much higher than in & 515-P humans. In addition, avian body temperatures range between 39 and 42oC, Meta-analysis of Genome-Wide Gene Expression Data from Glomer- they have a higher BMR, and are subjects to oxidative stresses comparable uli in Human Kidney with Diabetic Nephropathy or higher than humans. In spite of these factors, birds experience no diabetic KEIICHI KODAMA, SATORU YAMADA, KYOKO TODA, ATUL J. BUTTE, Stanford, complications and live longer than terrestrial animals of comparable body CA, Tokyo, Japan sizes [1]. For instance, pigeons with blood glucose of ~ 20 mM have a lifespan Genetic association studies have successfully revealed a number of of 20 years while rats with blood glucose of ~ 5 mM live for 2 years. important genes associated with diabetic nephropathy (DN). However, these The question is; how do birds do it?

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In an attempt to answer this question we are analyzing all the known Ad-PGC-1α in vivo. These data suggest that PGC-1α may protect DN through factors that may contribute to the capacity of birds to live with chronic inhibition of DRP1-mediated regulation of mitochondrial dynamic remodeling hyperglycemia, which would be deleterious and probably fatal to humans. In and ROS production. These fi ndings may help us to develop novel therapeutic order to gain a new perspective on this problem, we have elected to think of strategies to treat patients with DN. birds as a ‘pathology-free animal models of type 2 diabetes’. Supported By: EFSD/Chinese Diabetes Society; Eli Lilly and Company As a result of this altered point of view we noted a number of interesting biochemical differences between humans and birds. One of these differences 520-P is the apparent absence of an avian homolog to the ubiquitous mammalian POSTERS Investigating the Effects of Modifi ed Human Fibroblast Growth Complications RAGE gene (Receptor for Advanced Glycation End Products) that is a Factor in Diabetic Nephropathy Acute and Chronic contributor to the developments of diabetic complications [2]. In our analysis ANA M. PENA, LU CAI, SHALI CHEN, BIAO FENG, SUBRATA CHAKRABARTI, of this issue we examined all the completed vertebrate genomes available London, ON, Canada, Louisville, KY at the NCBI website (as of October 2013) for homologues to RAGE using Diabetic Nephropathy (DN) results from interactions involving metabolic an mRNA RAGE sequence [3]. Signifi cant homologies were found in all the and hemodynamic factors activated by hyperglycemia within kidney tissues. mammals examined but in none of the other vertebrates. Signifi cantly, this One of the prominent causes for renal damage is oxidative stress. Acidic latter category included three bird species (chicken, turkey and zebra fi nch). Fibroblast Growth Factor (aFGF) has been shown to confer protection from We postulate that absence of the RAGE gene in birds may be a factor in oxidative stress, function that is independent of its mitogenic activity. We avian resistance to chronic hyperglycemia. have generated a modifi ed human acidic FGF (maFGF), which is devoid of 1.Austad, S. ILAR J 2011;52:89. angiogenic activity. However, maFGF shows protective action from oxidative 2.Ramasamy R, et al. Ann NY Acad Sci 2011;1243:88. stress. Since hyperglycemia-induced oxidative stress plays an important 3.Neeper M, et al. J Biol Chem 1992;267:14998. role in the pathogenesis of DN, we hypothesized that mFGF treatment has a protective effect in DN. 518-P We investigated the effects of maFGF treatment on the biochemical, Global Toll-like Receptor 4 Knockout Results in Decreased Renal structural and functional changes in a mouse model of type I diabetes, Infl ammation, Fibrosis, and Podocytopathy in T1DM induced by STZ. Specifi c groups of diabetic animals were subjected to ISHWARLAL JIALAL, SRIDEVI DEVARAJ, Sacramento, CA, Houston, TX treatment with maFGF daily for 1 month or 6 months. Functional changes Type 1 Diabetes Mellitus (T1DM) is a pro-infl ammatory state as evidenced were determined through Urine Albumin-Creatinine ratio measurement. by circulating and cellular biomarkers of infl ammation. A pivotal receptor Expression of vasoactive and fi brogenic factors, extracellular matrix pathway explaining this increased infl ammation is the Toll-like receptor (TLR) accumulation (ECM) proteins and oxidative stress markers were tested. The pathway. Infl ammation appears to be crucial in the pathogenesis of diabetic morphological changes were confi rmed through histological analysis. nephropathy (DN). In this study we tested the effect of a global defi ciency MaFGF treatment didn’t show any effects in the body weight and blood of TLR4 on renal infl ammation, fi brosis and podocytopathy. Streptozotocin sugar compared to the diabetic group at 1 month or 6 months. It prevented (STZ) induced diabetes was induced in wildtype (WT) and TLR4-knockout renal functional alterations in diabetes at both time points, and prevented (TLR4KO) mice. Control (C) and diabetic groups (STZ-WT and STZ-TLR4KO) mice diabetes induced upregulation of vasoactive factors transcripts such as VEGF, were euthanized at 17 weeks and plasma and kidneys collected and frozen ANG and eNOS and the molecular marker of oxidative stress HO1 compared at -70oC. Compared to C, both diabetic groups had signifi cantly higher blood to diabetic groups. On the other hand, it failed to prevent alterations of glucose levels. Signifi cance was defi ned as p<0.05. However there were no fi brogenic factors such as TGF β1 mRNA, and ECM protein e.g. FN and Col 1α differences in weight, lipids, and creatinine levels. Compared to C, the STZ-WT (IV) mRNA expression. MaFGF has shown to exert the activation of the FGF group had signifi cantly increased macrophage staining (CD36 positivity) and receptors with all the downstream pathways associated with the tyrosine increased TLR4 immunostaining in the kidney. Both were signifi cantly reduced kinases which can act as a protective signal against oxidative stress. in the STZ-TLR4KO compared to the STZ-WT. Also there were signifi cant Supported By: CIHR increases in Myeloid Differentiation Factor 88, Interferon Regulatory Factor 3, Nuclear Factor Kappa B activity, Tumor Necrosis Factor Alpha and Interleukin 521-P 6 protein levels in the STZ-WT compared to C mice; all these parameters were Glucose 6-Phosphate Dehydrogenase Functions as a Novel Regu- signifi cantly decreased in the STZ-TLR4KO compared to the STZ-WT mice. lator to Mediate Hyperglycemia-induced Podocyte Injury During Compared to C, there were signifi cant increases in fi brosis markers, Collagen Diabetic Nephropathy 4, laminin, alpha actin and Transforming Growth Factor Beta in STZ-WT; all ZHAOYUN ZHANG, LINLING YAN, JI HU, YIMING LI, RENMING HU, ROBERT C. of these were signifi cantly decreased in the STZ-TLR4KO versus the STZ-WT. STANTON, Shanghai, China, Suzhou, China, Boston, MA Also staining for podocytes (WT-1) was decreased in the STZ-WT versus the Renal podocyte’s injury induced by hyperglycemia are early pathological C group and this was increased in the STZ-TLR4KO mice. In conclusion, a events of diabetic nephropathy (DN). Oxidative stress induced by hyperglycemia global genetic defi ciency of TLR4 ameliorates renal infl ammation, fi brosis and contributes to the injury in podocyte, but the mechanism remains largely podocytopathy and could be important in the pathogenesis of DN. unknown. NADPH supply plays an important role in the redox balance. Our Supported By: JDRF previous studies have shown that glucose 6-phosphate dehydrogenase (G6PD), the rate-limiting enzyme in pentose phosphate pathway providing 519-P cellular NADPH, was decreased in the kidney of diabetic mice. Here Protective Role of PGC-1a in Diabetic Nephropathy Is Associated we tested the hypothesis that suppression of G6PD might contribute to with the Inhibition of ROS through Mitochondrial Dynamic Remodel- hyperglycemia-induced oxidative stress and podocyte injury. Exposure of ing podocyte to high glucose (25 mM) decreased G6PD protein (45%), NADPH HAIBING CHEN, Shanghai, China level (40%), and GSH/GSSG (47%) as well as increased ROS accumulation The overproduction of mitochondrial reactive oxygen species (ROS) plays (26%). HG also inhibited podocyte proliferation and induced apoptosis, as a key role in the pathogenesis of diabetic nephropathy (DN). However, the refl ected by reduced MTT absorbance and increased cleaved-caspase 3 . underlying molecular mechanism remains unclear. Our aim was to investigate Importantly, adenoviral overexpression of G6PD in podocyte improved these the role of PGC-1α in the pathogenesis of DN. Diabetic and control rats were effects caused by HG. Conversely, knockdown of G6PD with siRNA reduced randomly infected with adenovirus expressing rat PGC-1α (Ad-PGC-1α) proliferation and increased apoptosis of podocyte. To further elucidate the or vehicle for 4 weeks. Also, rat glomerular mesangial cells (RMCs) were protective mechanism of G6PD, we observed HG disrupted the distribution incubated in normal or high glucose medium with or without the PGC-1α- pattern of F-actin, as visualized by fl uorochrome-conjugated phalloidin, and overexpressing plasmid (pcDNA3-PGC-1α) for 48 h. In the diabetic rats, this effect was reversed by G6PD overexpression. Interestingly, G6PD protein decreased PGC-1α expression was associated with increased mitochondrial was increased in podocyte incubated with MG132, a proteasome inhibitor, in ROS generation in the renal cortex, increased proteinuria, glomerular the presence of HG, compared to HG alone. Furthermore, compared to wild- hypertrophy, and higher glomerular 8-OHdG (a biomarker for oxidative stress). type mice, G6PD defi cient mice had a 65% decrease in podocyte number, as In vitro, hyperglycemia induced the down-regulation of PGC-1α, which led determined by WT-1 staining, and a 37% increase in urinary Alb/Cr. These to increased DRP1 expression, increased mitochondrial fragmentation and studies suggest G6PD suppression and/or degradation may represent a novel damaged network structure. This was associated with an increase in ROS mechanism by which hyperglycemia leads to increased oxidative stress and generation and mesangial cell hypertrophy. These pathological changes triggers podocyte injury, ultimately promoting the development of DN. were reversed by transfection of pcDNA3-PGC-1α in vitro and by injection of Supported By: NSFC (81370938, XYQ2011002)

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522-P the role of NAD metabolism in diabetic nephropathy has not been fully Peripheral CB1R Antagonism Improves Kidney Function in ZDF Rat elucidated. It has been postulated that free fatty acid-bound albumin (FFA- TONY JOURDAN, GERG SZANDA, JOSEPH TAM, BRIAN EARLEY, KATALIN albumin) fi ltered from glomeruli is a potent causal factor for tubulointerstitial ERDELYI, GRZEGORZ GODLEWSKI, RESAT CINAR, JIE LIU, CYTHIA JU, PÁL damage in diabetic patients with overt proteinuria and lipotoxicity-mediated PACHER, GEORGE KUNOS, Rockville, MD, Aurora, CO apoptosis plays central role in initiating the damage. In this study, a novel Diabetic nephropathy represents one of the major causes of end-stage enzyme in NAD metabolism, which is involved FFA-albumin induced tubular kidney disease. Increased activity of the endocannabinoid (EC) system damage, was screened. Among 19 candidate enzymes involved in NAD metabolism, the mRNA expression level of nicotinamide n-methyltransferase contributes to obesity-related type-2 diabetes (T2D) and its complications, POSTERS as refl ected by the benefi cial effects of chronic cannabinoid-1 receptor (NNMT) was signifi cantly increased in both the kidney of a mouse model of Complications (CB1R) blockade. Here we used a peripherally restricted CB1R antagonist FFA-albumin-overload nephropathy and cultured mouse proximal tubular Acute and Chronic to explore the role of CB1R in kidney dysfunction and the underlying cellular (mProx) cells stimulated with FFA-albumin. To reveal the role of NNMT in mechanisms in the Zucker diabetic fatty (ZDF) rat, a model of T2D-related FFA-albumin-induced kidney injury, we established NNMT-overexpressing nephropathy. Nephropathy was characterized by albuminuria, glycosuria, mProx cells using a retrovirus-mediated gene transfer system. FFA-albumin- reduced glomerular fi ltration rate, elevated plasma creatinine and urea, induced apoptosis, which was determined by cleavage of caspase 3 and activation of the renin-angiotensin system, oxidative and nitrative stress annexin-V-positive cells in FACS analysis, was signifi cantly decreased in and cell death. All of these changes, as well as the decreased number of the NNMT-overexpressing mProx cells. In addition, 1-MNA, a methylated podocytes and increased expression of CB1R in the diabetic glomeruli were product by NNMT, signifi cantly inhibited FFA-albumin-induced apoptosis in attenuated or reversed by chronic peripheral CB1R blockade. Whereas mProx cells. 1-MNA also signifi cantly ameliorated the tubular cell apoptosis in β-cell loss and the associated hyperglycemia of ZDF rats had been linked the mouse model of FFA-bound albumin overload nephropathy. In conclusion, to infi ltration of pancreatic islets by macrophages expressing CB1R and we identifi ed NNMT as a novel enzyme that inhibited lipotoxicity-mediated the Nlrp3 infl ammasome and could be prevented by macrophage depletion tubular cell apoptosis. Activation of NNMT may become a new strategy to or macrophage-specifi c knockdown of CB1R (Nat. Med. 19:1132, 2013), protect tubular cells against overt proteinuria in diabetic nephropathy. there was no signifi cant macrophage infi ltration of the ZDF kidney, and the nephropathy was unaffected by clodronate-mediated macrophage 525-P depletion. Exposure of cultured human podocytes to either high glucose or Rho-kinase Activation Induces Podocyte Loss via Notch Signaling the EC anandamide increased the expression of the carbohydrate response in Diabetic Nephropathy element-binding protein (ChREBP), CB1R, markers of oxidative stress, lipid KEIICHIRO MATOBA, DAIJI KAWANAMI, MASAMI TSUKAMOTO, JUN KINO- accumulation and ROS generation, and decreased the levels of podocin SHITA, SHO ISHIZAWA, YASUSHI KANAZAWA, TAMOTSU YOKOTA, KAZUNORI and nephrin, and these effects in both treatment groups were prevented UTSUNOMIYA, Tokyo, Japan by SiRNA-induced CB1R knock-down. These fi ndings support a key role of Rho-associated coiled-coil containing protein kinase (Rho-kinase) is a podocyte CB1R in the development of diabetic nephropathy independent downstream effector of small GTPase RhoA that has been shown to be from the associated hyperglycemia, and highlight the therapeutic potential implicated in the pathogenesis of diabetic nephropathy. Recent studies have of peripheral CB1R blockade. demonstrated that Notch pathway is a key regulator of podocyte loss and the onset of diabetic renal injury. However, the interactions of Rho-kinase 523-P and Notch signaling in the development of nephropathy have not been The Relationship between Fasting Blood Glucose Levels and End defi ned. In the present study, we assessed whether Rho-kinase inhibition Organ Damage Is Disassociated in Renovascular Hypertension attenuates Notch signaling and subsequent podocyte deletion using type 2 JOSEPH P. GRANDE, STELLA P. HARTONO, BRUCE E. KNUDSEN, Rochester, MN diabetic db/db mice and cultured podocytes (E11). Five-week-old db/db mice Atherosclerotic Renal Artery Stenosis (ARAS) and type II diabetes are were administered Rho-kinase inhibitor fasudil (100 mg/kg/day) for 3 weeks common co-morbidities found in the aging population. The purpose of through the drinking water. Urinary nephrin increased markedly in db/db this study was to determine whether renovascular hypertension induced mice, while fasudil dramatically suppressed the excretion. In vitro studies by ARAS accelerates progression of diabetes in db/db mice. We induced showed that recombinant TGF-β induced the expression of Notch ligand ARAS by placing a polytetrafl uoroethylene cuff on the right renal artery Jag1 and activated RhoA/Rho-kinase axis in podocytes. Pharmacological of C57BL/KS (wild type) or db/db (diabetic) mice. Contrary to expectation, and genetic inhibition of Rho-kinase blocked Jag1 induction. Importantly, diabetic mice with ARAS (n=60) had signifi cantly lower fasting glucose apoptosis and death of podocytes were inhibited by Rho-kinase blockade. levels compared to their age-matched sham controls (182±35 vs. 357±70 Furthermore, we found that Rho-kinase isoform ROCK2 is the key mediator of mg/dL, p=0.028), a change that was associated with an increased plasma Notch activation using isoform specifi c siRNAs. Mechanistically, Rho-kinase insulin levels (10.3±4.0 vs. 1.7±0.5 ng/mL, p=0.027). Db/db mice subjected regulated Jag1 induction via ERK1/2 and JNK, but not SMAD pathways. to ARAS developed progressive bilateral renal disease and had increased Our data indicated that the Rho-kinase activation might be involved in the cardiovascular mortality. We found no such differences in wild type mice loss of podocytes under diabetic conditions. The present study shows an subjected to ARAS or sham surgery. Administration of angiotensin receptor unrecognized mechanism for the renoprotective properties of Rho-kinase blocker (ARB) restored the fasting glucose values and plasma insulin levels inhibition and suggests that Rho-kinase could be regarded as a potential to those observed in sham db/db mice, while hydralazine produced no such therapeutic target for the treatment of diabetic nephropathy. effects despite equal reduction in systolic blood pressure. Both agents reduced chronic renal damage and cardiac remodeling. To determine if this 526-P phenomenon is related to leptin defi ciency in db/db mice, we performed Imaging Mass Spectrometry for the Detection of Metabolites in ARAS on C57BL/6 mice administered a fast-food diet (FFD, n=16) or standard Diabetic Kidney Disease chow (SC). Similarly, we found lower fasting glucose in the FFD mice with SATOSHI MIYAMOTO, PIETER C. DORRESTEIN, KUMAR SHARMA, La Jolla, CA ARAS vs. sham (157.9±7.4 vs. 180.8±5.9 mg/dL, p=0.048). Insulin resistance In spite of recent advances in the treatment and prevention of diabetic testing showed that, despite lower fasting glucose levels, FFD mice kidney disease (DKD), patients with diabetes remain at high risk for end- with ARAS developed a similar degree of insulin resistance as their age- stage renal disease, and therefore novel approaches are needed. We have matched sham controls. In conclusion, ARAS in db/db mice or mice with FFD recently identifi ed a urine metabolomic signature in patients with diabetic developed end organ damage and insulin resistance despite lower fasting nephropathy. To gain further understanding of the role of urine metabolites glucose levels. in the kidney, the integration of the differentially regulated urine metabolites Supported By: AI100911 with distribution of metabolites in kidney tissues will be of importance. Recent progress in the fi eld of matrix-assisted laser desorption/ionization 524-P imaging mass spectrometry (MALDI-IMS) has begun to shed light on the Nicotinamide N-methyltransferase Is a Novel Enzyme That Protects distribution of the metabolites in various organs. We applied MALDI-IMS to Proximal Tubular Cells from Lipotoxicity-mediated Apoptosis localize metabolites in kidney tissues between a mouse model of diabetic YUKI TANAKA, SHINJI KUME, HISAZUMI ARAKI, KEIJI ISSHIKI, SHIN-ICHI ARAKI, kidney disease (Akita) mice and wild type (WT) mice. In total we identifi ed DAISUKE KOYA, MASAKAZU HANEDA, TAKASHI UZU, HIROSHI MAEGAWA, 93 discrete mass-to-charge (m/z) values in the normal kidney and found Otsu, Japan, Kahoku, Japan, Asahikawa, Japan differences in 4 m/z values between Akita mice aged 8 weeks and WT mice. Modifi cation of nicotinamide adenine dinucleotide (NAD) metabolism has Using high-spatial resolution we analyzed the differences of the metabolites recently been proposed as a strategy for metabolic disorders. However, in the microstructure of the kidney tissues, and found that 6 m/z values

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were distributed specifi cally in the glomeruli in healthy mice. There was a C66 prevents diabetes-increased histone acetylation level and prevents similar distribution of the same 6 m/z values in healthy human glomeruli. the development and progression of DN. Importantly, we found that 2 of these m/z values were more abundant in Supported By: NSFC (81170669) glomeruli of Akita mice compared with control mice. These fi ndings provide a novel understanding of the pathogenesis of DKD and may lead to novel 529-P therapeutic targets for the treatment of DKD. Relationship between Monocyte Cell Surface CD163 and Soluble CD163 in Diabetic Complications

POSTERS 527-P DANQING MIN, BELINDA A. BROOKS, JENCIA WONG, BRIAN HARRISBERG, Complications Soluble Receptor for Advanced Glycation Endproducts Is Related to CHRISTINE YEE, STEPHEN M. TWIGG, DENNIS K. YUE, SUSAN MCLENNAN, Acute and Chronic Oxidative Stress in Patients with Diabetes Sydney, Australia JAN SKRHA, JR., JAN SOUPAL, MARTA KALOUSOVA, RADKA MIKOVA, MARTIN We have previously shown that monocyte phenotype is altered in asso- PRAZNY, JAN SKRHA, Prague, Czech Republic ciation with diabetic complications status. The relationship between these Oxidative stress (OxS) is believed to be the main player in the development changes and the development of complications and the mechanism of these of vascular damage in patients with diabetes. The aim of this cross-sectional changes is not known. A diabetic mouse model was used to investigate the study was to evaluate the relationship between OxS and levels of a novel temporal changes in CD163. The association between monocyte CD163, marker of endothelial changes - soluble receptor for advanced glycation sCD163 and proteinases, including matrix metalloproteinases (MMPs) endproducts (sRAGE). and neutrophil elastase (ELA2) involved in CD163 shedding was studied in Our study involved 104 patients with diabetes (45 Type 1 /T1DM/, aged humans. In mice, blood and urine were obtained at termination from control 52 ± 15 yrs and 59 Type 2 /T2DM/, aged 65 ± 11 yrs). OxS was measured by and diabetic mice at 5, 10 and 20 weeks duration of diabetes (n=5-8/grp). derivatives of reactive oxygen metabolites (d-ROMs) test while antioxidant ACR was determined as a measure of complications status. In humans, potency was evaluated by a biological antioxidant potential (BAP) test using blood was obtained from control (n=22) and diabetic patients (n=43) with Free Radical Analytical System (FRAS4; H&D, Italy). Routine biochemical duration of diabetes >10 years. The diabetic group included subjects without parameters, sRAGE, albuminuria (expressed as albumin-creatinine ratio / complications (n=25) and with complications (n=18). Monocyte CD163+ (%) ACR/) and biometrical data were measured in all patients. and sCD163 were determined by fl ow cytometry and ELISA respectively and We did not fi nd differences between T1DM and T2DM in both OxS in human plasma, ELA2, TIMP-1 and MMPs-2 and -9 were measured. expressed by d-ROMs (392 ± 115 vs. 388 ± 123 U, NS) and by BAP (1666 In diabetic mice, sCD163 was increased at 5 weeks and monocyte ± 541 vs. 1658 ± 471 µEq/L, NS). Similarly, sRAGE did not differ between %CD163+ was decreased at week 10, both P<0.05. These changes preceded groups (1352 ± 514 vs. 1179 ± 814 ng/l, NS). Interestingly, patients (T1 and an increase in ACR after 20 weeks duration. In humans, diabetes was T2DM together) with normal albuminuria (ACR<2.5 g/mol creatinine) had associated with decreased %CD163+ monocytes and increased circulating signifi cantly lower d-ROMs in comparison to patients with positive (micro) sCD163 but only in those with complications (by 16 and 1.6 fold respectively, albuminuria (368 ± 105 vs. 432 ± 134 U; p=0.009). Antioxidant capacity was all P<0.05). A similar pattern was observed for ELA2 (P<0.05). The MMP-2 not reduced signifi cantly in patients with positive albuminuria compared to and MMP-2/TIMP-1 ratio were increased (P<0.05) in all diabetes subjects those with normal albuminuria. Signifi cant inverse relationship was found irrespective of complication status. between BAP and sRAGE in both T1DM (r=-0.33, p<0.02) and T2DM (r=-0.26, Our inbred diabetic mouse data suggests that higher sCD163 and decreased p<0.05). On the contrary, d-ROMs were related with sRAGE in T2DM (r=0.42, monocyte %CD163+ precedes development of complications. The increased p<0.001), but not signifi cantly in T1DM (r=0.23, NS). sCD163 may be due to increased ELA2 and is consistent with increased This is the fi rst study describing inverse relationship between sRAGE monocyte activation and shedding. Moreover the observation these changes and protective antioxidant potency expressed by BAP in patients with are not observed in those patients who do not develop complications suggests diabetes. Higher oxidative stress can contribute to RAGE activation often a protective monocyte phenotype in this subgroup patient. associated with endothelial activation/dysfunction. However, follow-up study elucidating these processes will be necessary. 530-P Supported By: Charles University SGLT2 Inhibitor Luseoglifl ozin (TS-071) Protects from Diabetic Nephropathy in an Animal Model of Type 2 Diabetes 528-P YUMI TAKIYAMA, RYOICHI BESSHO, MANAMI MAEDA, KURALAY K. Novel Curcumin Analog C66 Prevents Diabetic Nephropathy via ATAGELDIYEVA, TSUYOSHI YANAGIMACHI, JUN HONJO, YUKIHIRO FUJITA, JNK Pathway with the Involvement of p300/CBP-mediated Histone YUICHI MAKINO, MASAKAZU HANEDA, Asahikawa, Japan Acetylation SGLT2 inhibitors represent a promising strategy in the treatment of YANGWEI WANG, YONGGANG WANG, LINING MIAO, LU CAI, Changchun, China, diabetes by targeting renal proximal tubules. To determine their potential Louisville, KY renal protective effects and mechanisms, we treated db/db mice with 15 Some profi brotic factors such as connective tissue growth factor mg/kg/day luseoglifl ozin for 8 weeks. The regulation of SGLT2 expression (CTGF), plasminogen activator inhibitor-1 (PAI-1) and fi bronectin 1 (FN1) was also examined in vitro using human renal proximal tubular epithelial play a major role in glomerulosclerosis and interstitial fi brosis, which are cells (HRPTEC) by RT-qPCR. key events in the pathogenesis of diabetic nephropathy (DN). Curcumin, Luseoglifl ozin markedly lowered HbA1c levels by 50% in hyperglycemic db/ a polyphenol, has numerous pharmacological properties. The present db mice (p<0.001). Luseoglifl ozin signifi cantly attenuated urinary albumin/ study aimed to investigate whether curcumin analog C66 can prevent DN creatinine ratio by 70% (p<0.05), and also decreased glomerular mesangial in streptozotocin-induced diabetic mice via inhibition of JNK pathway matrix expansion, glomerular and interstitial fi bronectin accumulation in db/ and epigenetic histone acetylation. Diabetic and age-matched control db mice. Consequently, luseoglifl ozin preserved the expression of SGLT2 in mice were treated with C66, c-Jun N-terminal kinase inhibitor (JNKi, brush border membrane of the proximal tubules of db/db mice. Of interest, sp600125) or vehicle (1% CMC-Na solution) at 5 mg/kg for three months. luseoglifl ozin augmented pimonidazole staining in the outer stripe of outer At the end of 3-month treatment, one set of both diabetic and control mice medulla in db/db mice, suggesting hypoxia caused by the overload of glucose were aged for additional 3 months without further treatment. At the 3rd and sodium via SGLT1-mediated compensatory reabsorption. HRPTEC and 6th months, C66 treatment signifi cantly prevented diabetes-induced constitutively expresses SGLT2 mRNA, not SGLT1 mRNA. Chronic hypoxia has renal fi brosis and dysfunction, which was mediated by suppressing JNK been recognized as a key regulator in renal tubulointerstitial fi brosis in diabetic pathway since JNKi treatment showed a renal protection similar to the nephropathy, which is associated with the activation of HIF-1alpha. Signifi cant effect of C66. Diabetic increases in the histone acetylation, histone acetyl decrease in SGLT2 mRNA expression was observed by hypoxia (64.5±3.3%, transferases (HATs) activity, and expression of specifi c HAT p300 and CBP p<0.01). However, neither lowering of HIF-1alpha by siRNA nor the antioxidant were signifi cantly attenuated by C66 or JNKi treatment. Examining the H3- N-acetylcysteine restored SGLT2 mRNA, indicating that hypoxia-induced lysine9/14-acetylation (H3K9/14Ac) levels and p300/CBP occupancy on the decrease in SGLT2 mRNA is independent of HIF-1alpha or oxidative stress. In promoters of CTGF, PAI-1 and FN1by chromatin immunoprecipitation assays accordance with the histological fi ndings in vivo, luseoglifl ozin signifi cantly revealed that both C66 and JNKi treatments decreased the H3K9/14Ac inhibited TGF-beta1-induced fi bronectin expression. enrichment and p300/CBP occupancy on the promoters of CTGF and PAI- Taken together, these data demonstrate that luseoglifl ozin can protect against 1. These results suggest that in the kidney C66 is able to down regulate the progression of diabetic nephropathy, which is probably suffi cient to overcome diabetic activation of JNK and increase in total HAT activity, and also the adverse effects of TGF-beta1 or hypoxia on proximal tubular cells. down regulate diabetes-increased p300/CBP expression, through which Supported By: Taisho Pharmaceutical Co., Ltd.

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A136 COMPLICATIONS—NEPHROPATHY—CLINICAL AND TRANSLATIONAL RESEARCH

531-P alone has not been shown to lead to a reduction in glomerular fi ltration rate Lithospermic Acid B Improved Hyperglycemia-induced Glomerular (GFR) in rats, ZDSD animals underwent unilateral nephrectomy to reduce renal Mesangial Cell Fibrosis by Suppression of TGF-β1-Snail Signaling mass to accelerate renal injury prior to the induction of hyperglycemia. EUN YOUNG LEE, SOO HYUN KIM, YONG-HO LEE, BYUNG-WAN LEE, EUN SEOK Two thirds of the diabetic untreated animals had elevated albuminuria and KANG, BONG SOO CHA, HYUN CHUL LEE, Seoul, Republic of Korea reduced GFR, suggesting that this model recapitulates key parameters of impaired In our previous study, we demonstrated that lithospermic acid B (LAB), an renal function in diabetic nephropathy. Treatment of the diabetic animals with active component isolated from Salvia miltiorrhizae, decreases transforming VPI-2690B, captopril, or the combination resulted in a reduction in albuminuria. This reduction was statistically signifi cant in animals treated with VPI-2690B growth factor-β (TGF-β1) and renal fi brosis in diabetic rats. Recently it has POSTERS been shown that activation of Snail leads to renal fi brosis. As TGF-β1 has been alone or in combination with captopril, with the lowest levels of albuminuria Complications known to regulate Snail expression, we investigated whether anti-fi brotic observed in the group of animals treated with VPI-2690B and captopril in Acute and Chronic effect of LAB is through expression of Snail. Murine mesangial cells cultured combination. The decrease in GFR was partially reversed by treatment with VPI- in high glucose media and kidney samples from type 2 diabetic OLETF rats 2690B, captopril, or VPI-2690B and captopril in combination, with the greatest were used for the study. The expressions of TGF-β1, Snail, and fi bronectin improvement observed in the animals treated with the combination. There was were analyzed by Western blot or PCR. Furthermore, the effect of Snail on no antagonism of the effect of either agent by the other in this study. renal fi brosis was evaluated in cells with overexpression or suppression of This study reports the initial characterization of an exploratory model Snail by either co-transfection of pcDNA3-Snail or interference mRNA. The of diabetic nephropathy in the uni-nephrectomized ZDSD rat, which expressions of TGF-β1, Snail, and fi bronectin were increased in response to recapitulates two key parameters of human diabetic nephropathy. Both glucose concentration in mesangial cells. Exogenous TGF-β1 induced Snail of these parameters are improved by treatment with VPI-2690B. The data and fi bronectin expression. Conversely, TGF-β1 inhibitor decreased Snail and also suggest the potential for additive benefi t on renal function from the fi bronectin expression. Under normal glucose condition, Snail overexpression addition of VPI-2690B to an ACE inhibitor and demonstrate the absence of increased fi bronectin expression in mesangial cells, whereas under high any negative pharmacological interaction between these two agents. glucose condition, Snail knockdown by siRNA decreased fi bronectin expression in mesangial cells. To investigate the effect of LAB on these signaling 534-P pathways, LAB was treated with various concentrations in mesangial cells. Deletion of mDia1 Is Protective in a Murine Model of Diabetes and LAB treatment decreased TGF-β1, Snail, and fi bronectin expression in a dose Nephropathy dependent manner. Under high glucose condition, LAB treatment and TGF-β1 MICHAELE B. MANIGRASSO, ROSA ROSARIO, RAVICHANDRAN RAMASAMY, inhibitor showed similar effects on Snail and fi bronectin expression without VIVETTE D. D’AGATI, ANN MARIE SCHMIDT, New York, NY additive effects. Our results demonstrated that the TGF-β1 induced renal Our studies have shown the cytoplasmic domain of the receptor for fi brosis in high glucose condition is mediated by the transcription factor Snail advanced glycation endproducts (RAGE) binds to the formin molecule, and this process is inhibited by LAB. These results suggest that LAB may be diaphanous-1 (mDia1). mDia1 is a member of the formin family of intracellular used to ameliorate renal fi brosis of diabetic nephropathy. molecules involved in cellular migration which act as effectors of Rho GTPase signaling. In RAGE-expressing cells devoid of mDia1, incubation with 532-P RAGE ligands failed to generate reactive oxygen species or activate key Dapaglifl ozin Ameliorates Diabetic Nephropathy by Suppressing signaling cellular stress pathways. Here, we sought to determine if mDia1 Infl ammation and Oxidative Stress in db/db Mice plays key roles in diabetic nephropathy (DN). Our preliminary data reveal DAISUKE OGAWA, TAKASHI HATANAKA, NAOTO TERAMI, HIROMI TACHIBANA, that mDia1 expression is increased in human and murine diabetic kidneys ATSUKO NAKATSUKA, JUN EGUCHI, NAOKO NISHII, JUN WADA, HIROFUMI and expression patterns of mDia1 are highly analogous to RAGE expression MAKINO, Okayama, Japan patterns. In the diabetic glomerulus, RAGE and mDia1 are highly expressed Inhibition of sodium glucose cotransporter 2 (SGLT2) has been reported as a in podocytes. While the role of RAGE has been shown to play a key role in novel therapeutic approach for treating diabetes. However, the effect of SGLT2 the development of DN, the potential contribution of mDia1 has yet to be inhibitors on the kidney is unknown. In addition, whether SGLT2 inhibitors have elucidated. Therefore, we tested the hypothesis that mDia1 contributes to an anti-infl ammatory or antioxidative stress effect is still unclear. In this study, the development and progression of DN in a murine model. to resolve these issues, we investigated the effects of the SGLT2 inhibitor, This preliminary study suggests that deletion of mDia1 in mice results dapaglifl ozin, using a mouse model of obesity and type 2 diabetes. Eight- in a substantial protection against indices of DN by reducing podocyte week-old male db/db mice were treated with 0.1 or 1.0 mg/kg of dapaglifl ozin effacement, infl ammation and fi brosis in type 1 DM. for 12 weeks. Body weight, blood glucose, hemoglobin A1c, urinary albumin excretion, creatinine clearance and blood pressure weremeasured. Mesangial matrix accumulation and interstitial fi brosis were evaluated by histological COMPLICATIONS—NEPHROPATHY—CLINICAL AND analysis. Furthermore, gene expression of infl ammatory mediators, such TRANSLATIONAL RESEARCH as monocyte chemoattractant protein-1, transforming growth factor-β and osteopontin, was evaluated by quantitative reverse transcriptase- polymerase chain reaction. In addition, oxidative stress was evaluated by Guided Audio Tour: Complications—Nephropathy—Clinical and Transla- dihydroethidium and NADPH oxidase 4 staining. Administration of 0.1 or 1.0 tional Research (Posters: 535-P to 540-P), see page 17. mg/kg of dapaglifl ozin ameliorated hyperglycemia and albuminuria in db/db mice. Serum creatinine, creatinine clearance and blood pressure were not & 535-P affected by the administration of dapaglifl ozin, but glomerular mesangial Elevated Circulating Pigment Epithelium-derived Factor Predicts the expansion and interstitial fi brosis were suppressed in a dose-dependent Progression of Diabetic Nephropathy in Type 2 Diabetic Patients manner. Dapaglifl ozin treatment markedly decreased gene expressions of ELAINE HUI, CHUN-YIP YEUNG, PAUL C.H. LEE, YU-CHO WOO, CAROL H.Y. FONG, macrophages and infl ammatory cytokines in the diabetic kidney. Moreover, AIMIN XU, KAREN SIU LING LAM, Hong Kong, China dapaglifl ozin suppressed diabetes-induced oxidative stress in the kidney. Pigment epithelium-derived factor (PEDF) is a multifunctional glycoprotein These data suggest that dapaglifl ozin ameliorates diabetic nephropathy by with potent anti-angiogenic, anti-oxidative and anti-infl ammatory properties. inhibiting infl ammation and oxidative stress in db/db mice. PEDF halts the development and progression of diabetic nephropathy in experimental animal models but its role in humans remains unclear. Here we 533-P investigated whether circulating PEDF levels predicted the development of VPI-2690B, a Novel Alphavbeta3 Integrin Antibody, Reduces Hyper- diabetic nephropathy in a 4-year prospective study. glycemia-induced Changes in Renal Function in a Rat Model of Baseline plasma PEDF levels were measured with an ELISA in type 2 Diabetic Nephropathy diabetic subjects, recruited from the Hong Kong West Diabetes Registry. LAURA MAILE, KATHERINE GOLLAHON, YALIN XIONG, JIEWU LIU, AMYN MUR- The role of PEDF in predicting chronic kidney disease (CKD) and albuminuria JI, MEGHAN SHEA, DAVID CLEMMONS, Chapel Hill, NC progression was analyzed using Cox regression analysis. CKD progression A novel model of renal injury was used to examine the effect of VPI-2690B, was defi ned as a deterioration in CKD staging and a 25% or greater drop an anti-αVβ3 integrin antibody that targets a non-RGD binding site region of the in estimated glomerular fi ltration rate (eGFR) from baseline, as defi ned by integrin, in comparison to and in combination with the ACE inhibitor, captopril, International Society of Nephrology statements. (standard of care for diabetic nephropathy). The ZDSD rat (Preclinomics Inc) At baseline, plasma PEDF levels increased progressively with CKD staging develops hyperglycemia in response to high-fat diet. Since hyperglycemia (P for trend <0.001; n=1136). Amongst 1071 subjects with baseline CKD

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A137 COMPLICATIONS—NEPHROPATHY—CLINICAL AND TRANSLATIONAL RESEARCH

stage ≤ 3, plasma PEDF levels were signifi cantly higher in those with CKD by viral transfection with tg B7.1 or B7.1 siRNA is associated respectively progression (n=171) during follow-up than those with no progression (n=900) with increased or reduced HG-induced damage. CTLA4-Ig treatment of db/ (P<0.001). PEDF was independently associated with CKD progression (hazard db and STZ-C57BL/6 mice (500 µg at day 0; 250 µg at day 2, 4, 6, 8, 10; 250 µg ratio: 3.55; 95% CI: 1.92-6.59; P<0.001), after adjustment for age, sex, duration twice a week thereafter) prevented urinary albumin excretion rise (UAE, db/ of diabetes, systolic blood pressure, use of renin-angiotensin inhibitors and db: untreated 7wks vs. 25wks; p=0.003; CTLA4-Ig-treated 7wks vs. 25wks; C-reactive protein. Elevated baseline PEDF was also associated with the p=ns); glomerular alterations (mesangial expansion, collagenen I deposition development of albuminuria in a subgroup without albuminuria and eGFR>60 and podocytes apoptosis) were also prevented by CTLA4-Ig treatment. The ml/min/1.73m2 (n=462), at baseline (hazard ratio: 3.69; 95% CI: 1.47-9.24; data showed and the presence of a clinically available compound candidate POSTERS

Complications P=0.005), even after adjustment for potential confounders. B7-1 as a new therapeutic target for DN.

Acute and Chronic Elevated PEDF levels may represent a compensatory change in diabetic Supported By: ADA (7-11-MN-17) patients with renal disease and appear to be a useful marker for evaluating the progression of diabetic nephropathy in patients with type 2 diabetes. & 538-P Supported By: Hong Kong Research Grants Council (CRF HKU 02/12R) Differential Factors for Diabetic Nephropathy and Retinopathy HILLARY A. KEENAN, SHANE FITZGERALD, STEPHANIE M. HASTINGS, JENNIFER & 536-P K. SUN, ZHIHENG H. HE, MOGHER KHAMAISI, GEORGE L. KING, Boston, MA Plasma Adrenomedullin and Renal Outcomes in Patients with Type Diabetic patients with nephropathy (DN) most often develop retinopathy 2 Diabetes (DR) as well, but those with DR frequently do not have DN suggesting that GILBERTO VELHO, KAMEL MOHAMMEDI, ELISE GAND, FRÉDÉRIC FUMERON, causal and protective factors may differ. To identify these factors, we studied MATHILDE FRATY, PIERRE-JEAN SAULNIER, STÉPHANIE RAGOT, MICHEL a rare subset who had DN (eGFR <45 mL/min/1.73 m2) but lacked proliferative MARRE, SAMY HADJADJ, RONAN ROUSSEL, Paris, France, Poitiers, France DR (PDR) among those in the Joslin 50 Year Medalist Study, individuals with Adrenomedullin (ADM) is a vasodilator peptide secreted mainly in 50 or more years of type 1 diabetes. We compared them to Medalists with endothelial cells in response to cellular strain, including hypoxia and ischemia. DN and PDR (+DN/+PDR), no DN and with DR (-DN/ + PDR), and no DN and High levels of circulating ADM were observed in heart failure, myocardial no DR (-DN/-PDR). Of those with DN (+DN/-PDR and +DN/+PDR) the mean infarction and arterial hypertension. The mid-regional part of pro-ADM (MR- eGFR, serum creatinine and ACR in the groups were 38.7±7.2 v 33.0±9.2 mL/ proADM) is a surrogate marker of ADM. Here we examined the association min/1.73 m2, 1.6±0.5 v 1.8±0.8 mg/dL, 17.8 [6.9, 48.7] v 47 [12.3, 158.7] mcg/ of MR-proADM plasma levels with the risk of severe renal events (doubling mg , respectively; no differences in daily insulin dose (34.2±13.3 v 34.9±16.2 of serum creatinine levels or the requirement of hemodialysis or renal u) or smoking (0% v 3.1% ) prevalence were found. Surprisingly, those +DN/- transplantation) during follow-up in two prospective cohorts of French type PDR had lower rates of cardiovascular disease than expected for those 2 diabetic patients: DIABHYCAR (n=2962; median follow-up of 4.7 years) and with renal disease: +DN/-PDR 33.3%, +DN/+PDR 71.1%, -DN/+PDR 44.3% SURDIAGENE (n=1351; median follow-up of 5 years). and -DN/ -PDR 30.9%. Those with +DN/-PDR had higher age at diagnosis The cumulated incidence of renal events during follow-up was 2.4% (n=73) (15.7±7.1, 10.8±6.2, 11.2±6.4, 10.6±5.7 yr), age (73.0±6.7, 67.4±7.0, 66.6±7.4, for DIABHYCAR and 6.0% (n=81) for SURDIAGENE. In DIABHYCAR, the 65.1±7.1 yr), and triglycerides (85.3±34.3, 87.7±39.4, 71.7±32.3, 77.6±43.3 incidence of renal events by tertiles of MR-proADM was 1.0% (T1), 1.9% (T2) mg/dL) but lower HDLc (58.0±24.6, 59.0±16.5, 67.1±20.2, 63.7±18.5 mg/dL). and 4.5% (T3): Hazard Ratio (HR) 5.4, 95% C.I. 2.8-11.4 (p<0.0001, T3 vs. T1, Interestingly, within +DN groups, the c-peptide level was higher in those all analysis adjusted for sex and age). It was 4.0% (T1), 4.6% (T2) and 10.6% -PDR than +PDR: 0.12 [0.05, 0.24] v 0.05 [0.05, 0.18] ng/ml, p=0.08. There (T3) for the subset of subjects with macroalbuminuria at baseline (n=700): HR were no differences across the four groups in HbA1c, BMI, sex, IL-6, PAI1, 3.6, 95% C.I. 1.7-8.3 (p=0.0006, T3 vs. T1). Associations remained signifi cant VCAM levels, IA2 or GAD positivity or co-existing autoimmune conditions. when adjusted for estimated glomerular fi ltration rate (eGFR), arterial Post-mortem pathology in +DN/-PDR (n=4) confi rmed classic clinical DN hypertension and coronary artery disease status (history of angina pectoris with classic glomerular pathology (DN class IIB and III). These data show or myocardial infarction) at baseline. The yearly variation of eGFR during for the fi rst time it is possible to have severe DN without DR. In this group follow-up by tertiles of MR-proADM was -0.77 ± 0.23 (T1), -1.14 ± 0.23 (T2) the presence of PDR with DN is associated with an increased prevalence and -1.78 ± 0.23 ml/min.year-1 (T3) (mean ± SEM, ANCOVA p=0.008). Results of CVD, and, older age at diabetes onset and retention of beta cell function were replicated in SURDIAGENE: the incidence of renal events by tertiles of possibly offer greater protection for DR than DN. MR-proADM was 1.5% (T1), 2.4% (T2) and 14.0% (T3); HR 26, 95% C.I. 11-61 Supported By: JDRF; NIH (p<0,0001, T3 vs. T1). In conclusion, high levels of plasma MR-proADM were associated & 539-P with increased risk of severe kidney complications in patients with type Nonlinear Relationship between Estimated Glomerular Filtration 2 diabetes. The pathophysiological mechanisms behind the association Rate and Mortality in Type 2 Diabetes: The Fremantle Diabetes remain unclear. Study TIMOTHY M.E. DAVIS, DAVID BRUCE, WENDY A. DAVIS, Fremantle, Australia & 537-P Previous studies in type 1 diabetes have shown a U-shaped relationship Podocyte B7-1 Inhibition as a Therapeutic Strategy for Diabetic between estimated glomerular fi ltration rate (eGFR) and all-cause death. Nephropathy Patients with eGFR>120 and <60 mL/min had higher mortality than those with ANDREA VERGANI, ROBERTO BASSI, MONIKA A. NIEWCZAS, MARCUS PEZZO- eGFR 60-120 mL/min. We examined whether this applies in type 2 diabetes LESI, ANDRZEJ S. KROLEWSKI, PETER MUNDEL, PAOLO FIORINA, Boston, MA by analyzing data from 1,296 Fremantle Diabetes Study patients (mean age Glomerular podocytes, damaged during diabetic nephropathy (DN), may 64.0±11.3 yrs, 48.6% males, median [IQR] diabetes duration 4.0 [1.0-9.0] yrs) express B7-1 (or CD80). B7-1 upregulation leads to podocyte alteration and recruited from 1993 to 1996 and followed until end-2012. During 12.9±6.1 specifi c B7.1-targeting therapy (CTLA4-Ig/Abatacept) may be protective (range 0-19.7) yrs of follow-up, 738 (56.9%) died. In a Cox proportional from high glucose(HG)-induced damage. To assess the relevance of the B7.1 hazards model with age as timeline, independent predictors of death were path in DN development, we investigated B7.1 expression in kidney biopsies male sex, Aboriginality, current smoking, prior ischemic heart disease, from T2D patients: glomerular B7-1 upregulation was observed compared to peripheral arterial disease, albuminuria, and systolic BP (inversely) (P<0.001), controls (n=30); B7.1 upregulation was proportional to disease progression. and retinopathy, diastolic BP, BMI, and exercise (inversely) (P≤0.035). There 173 T2DN cases were then screened for single-nucleotide polymorphisms was also a U-shaped relationship between eGFR and death. (SNPs) in the B7-1 gene and a specifi c SNP was associated with progression Categories of Baseline eGFR in the Cox Proportional Hazards Mortality to end stage renal disease (ESRD; SNP rs2629396 OR=1.56, p=0.008); Model. epidemiologic studies were performed on the Joslin Clinic cohort of T2D eGFR category Number of Hazard 95% confi dence P-value and soluble (s)CD28 (B7-1 ligand) was measured: sCD28 serum baseline patients ratio interval levels predicted ESRD progression in T2D patients. In vitro B7-1 was also upregulated on immortalized murine podocytes when cultured in HG (30 ≥90 195 2.69 1.94-3.72 <0.001 mM) and in vivo B7.1 was upregulated on glomerular podocytes of db/db 60-89 533 1.32 1.08-1.61 0.006 and streptozotocined (STZ)-C57BL/6 mice. Pharmacological targeting of 45-59 (reference) 349 1.00 B7-1 with CTLA4-Ig, is benefi cial in protecting podocytes in vitro from HG- 30-44 163 1.22 0.97-1.54 0.09 induced damage (deregulation of podocyte-specifi c cytoskeleton proteins and apoptosis); consistently B7.1 upregulation or dowregulation induced <30 43 1.17 0.77-1.77 0.46

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A138 COMPLICATIONS—NEPHROPATHY—CLINICAL AND TRANSLATIONAL RESEARCH

Given the present patients were on average >25 years older than those in type 1 studies and the 0.75 mL/min/yr decline in eGFR with age, the present Table 1. Multivariate Regression Results for Outcome of Continuous UACR data parallel those in type 1 diabetes. We conclude that i) a relatively and Categorical MA. high eGFR in type 2 diabetes indicative of past/present hyperfi ltration is Covariates Outcome for Outcome for follow up an adverse prognostic indicator, and ii) inclusion of eGFR in multivariable follow-up UACR microalbuminuria analysis of outcomes such as death should respect its non-linearity. Beta (p-value) OR (95% CI) Supported By: University of Western Australia Baseline UACR 0.16 (0.002) --

Baseline Microalbuminuria -- 1.3 (0.5, 3.2) POSTERS & 540-P Socioeconomic Indicators Complications Highly Multiplexed Proteomic Analysis Identifi es Novel Plasma -Health insurance 0.02 (0.4) 1.7 (0.8, 3.4) Acute and Chronic Biomarkers for Early Progressive Renal Function Decline Leading - Parents education >= Bachelors 0.01 (0.5) 1.5 (0.9, 2.5) to Renal Failure in Type 1 Diabetes Demographics MARCUS G. PEZZOLESI, MALTI NIKRAD, KEVIN P. MCDONNELL, ADAM M. -Age at Diagnosis -0.007 (0.01) -- SMILES, NATALIA NOWAK, ANDRZEJ S. KROLEWSKI, Boston, MA, Boulder, CO -NHW Ethnicity 0.009 (0.6) -- Progressive renal function decline is the fundamental disease process -Male Gender 0.05 (0.009) -- that underlies the development of renal failure in Type 1 diabetes (T1D). To Baseline Clinical Variables determine the protein signature that is associated with initiation of early -A1c 0.0 (1.0) 1.2 (1.0, 1.4) progressive renal function decline, we compared the baseline plasma -SBP Z-score -- -- protein signatures of 38 Decliners and 40 Non-decliners using SomaLogic’s -BMI Z-score -- -- -Current smoker -0.05 (0.2) -- SOMAscan proteomic technology that employs slow off-rate modifi ed aptamers to simultaneously assay 1,129 proteins. Decliners were defi ned Follow-up Clinical Variables as T1D patients with proteinuria and normal renal function at baseline who -A1c -0.03 (<0.0001) 0.9 (0.8, 1.1) developed renal failure during 5-15 years of follow-up. Non-decliners were -SBP Z-score -- -- -BMI Z-score 0.003 (0.04) 0.0 (1.0, 1.0) defi ned as long duration T1D patients with normoalbuminuria and normal -Current smoker -- 1.5 (0.8, 3.0) renal function at baseline who maintained stable renal function during 10 years of follow-up. Comparison of the protein expression profi les of these Supported By: NIH; CDC study groups identifi ed 37 proteins (3.3%) with <0.5 or >2.0 fold changes between Decliners and Non-decliners and FDR p-values <0.01. A total of 542-P 103 proteins (9.1%) showed <0.7 or >1.3 fold changes between Decliners and Non-decliners and FDR p-values <0.01. Hydolases, transferases, and WITHDRAWN receptor proteins were among the top proteins increased in Non-decliners while signaling molecules and kinases were included in the top proteins increased in Decliners. Efforts to confi rm these fi ndings in additional Decliners (n=40) and Non-decliners (n=40) with moderately reduced renal function at baseline (eGFR 30-59ml/min) are ongoing. We anticipate that the combined results of these two studies will demonstrate that large-scale proteomic analysis can be used to distinguish individuals who are at high risk of renal function decline and progression to renal failure from those who are protected against this complication. Supported By: NIH/NIDDK (DK041526)

541-P The Early Natural History of Albuminuria in Children with Type 1 Diabetes AMY K. MOTTL, NORA FITZGERALD, ELIZABETH MAYER-DAVIS, JASMIN DIVERS, DANA DABELEA, SHARON H. SAYDAH, JEAN M. LAWRENCE, LAWRENCE M. DOLAN, AMY S. SHAH, MARYAM AFKARIAN, DAVID J. PETTITT, SANTICA M. MARCOVINA, DAVID M. MAAHS, FOR THE SEARCH FOR DIABETES IN YOUTH STUDY GROUP, Chapel Hill, NC, Winston-Salem, NC, Aurora, CO, Atlanta, GA, Pasadena, CA, Cincinnati, OH, Seattle, WA, Santa Barbara, CA Given its tendency to fl uctuate, the use of microalbuminuria (MA) as a threshold value to denote higher risk for diabetic kidney disease (DKD) has come under scrutiny. Our goal was to: 1) evaluate the regression and progression of MA over an average period of 8 years and 2) evaluate the association of baseline MA (categorical) and baseline continuous urine albumin:creatinine ratio (UACR) with their respective follow-up values. Data from the cohort component of SEARCH were used including 1056 youth with newly diagnosed type 1 diabetes (T1D). Baseline characteristics included: age=9.0±4.3 years, 58% male, 81% non-Hispanic White, T1D duration=96±18 months, A1c=9.0±1.7%). UACR was calculated from random urine specimens at baseline and follow-up. MA was defi ned as UACR ≥30µg/ mg. Multivariate models predicting follow-up UACR or follow-up MA were adjusted for baseline UACR or baseline MA, respectively, and for other covariates. Covariates not signifi cant in univariate analyses(p<0.2) were not incorporated into the multivariate analysis. 543-P Of 78 participants with baseline MA, 90% regressed to normoalbuminuria, Sodium Glucose Cotransport-2 Inhibition Increases Urinary ACE2 and of 978 with baseline normoalbuminuria, 8% progressed to MA. Baseline Levels in Patients with Type 1 Diabetes UACR, male gender, and follow-up A1c and BMI-Z predict follow-up UACR KEVIN BURNS, BRUCE A. PERKINS, NIMA SOLEYMANLOU, FENGXIA XIAO, (Table 1). JOSEPH ZIMPELMANN, HANS J. WOERLE, ODD ERIK JOHANSEN, ULI C. Our data suggest that changes in continuous UACR may be a more BROEDL, MAXIMILIAN VON EYNATTEN, DAVID CHERNEY, Ottawa, ON, Canada, useful predictive tool in diagnosing DKD than the current method of Toronto, ON, Canada, Burlington, ON, Canada, Ingelheim, Germany categorization. Sodium Glucose Cotransport-2 (SGLT2) inhibition with empaglifl ozin (EMPA) in type 1 diabetes (T1D) patients attenuates renal hyperfi ltration (NCT01392560) via effects on tubuloglomerular feedback, resulting in

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A139 COMPLICATIONS—NEPHROPATHY—CLINICAL AND TRANSLATIONAL RESEARCH

decreased GFRINULIN and renal plasma fl ow (RPF). EMPA also reduced blood 545-P pressure by 3 mmHg, likely through diuretic effects, refl ected by mild Renoprotective Effect of Linagliptin on Free Fatty Acids-bound increases in haematocrit, urea, plasma aldosterone and angiotensin (Ang) II. Albumin-induced Tubulointerstitial Injury in Mice However, the effect of SGLT2 inhibition on the intrarenal renin-angiotensin YUKI TANAKA, SHINJI KUME, SHIN-ICHI ARAKI, DAISUKE KOYA, MASAKAZU system is unknown. Recent data support the renoprotective role of HANEDA, ATSUNORI KASHIWAGI, TAKASHI UZU, HIROSHI MAEGAWA, Otsu, angiotensin-converting enzyme 2 (ACE2) pathways in diabetes, through the Japan, Kahoku, Japan, Asahikawa, Japan conversion of Ang II to Ang-(1-7). Urinary ACE2 can be detected in patients Renal prognosis in patients with diabetic nephropathy depends on severity with uncomplicated T1D, suggesting that diabetes stimulates ACE2 release

POSTERS of tubulointerstitial injury induced by massive proteinuria. Establishment of

Complications from tubular cells. In this post-hoc exploratory analysis, we determined the new therapeutic strategy against proteinuria-induced tubulointerstitial injury Acute and Chronic effect of EMPA-induced glucosuria on urinary ACE2 excretion, in presence in diabetic nephropathy is required. Dipeptidyl peptidase (DPP)-4 inhibitors and absence of clamped hyperglycemia. have recently been suggested exerting pleiotropic effects beyond glucose Creatinine-corrected urinary ACE2 activity and protein levels were lowering. We thus examined renoprotective effect of linagliptin, a DPP-4 measured in 40 T1D patients during clamped euglycemia (4-6 mmol/L) and inhibitor, in a non-diabetic mouse model of renal tubulointerstitial injury hyperglycemia (9-11 mmol/L) before and after EMPA 25 mg QD for 8 weeks. which induced by intraperitoneal injection of free fatty acids (FFA)-bound EMPA increased urinary ACE2 protein during clamped euglycemia (5.6±1.0 albumin. Mice were fed either standard diet (SD) or SD with linagliptin, and to 10.5±1.2 ng/mmol, p=0.001) and hyperglycemia (5.0±0.7 to 8.0±0.8 ng/ intraperitoneally injected with FFA-bound albumin or PBS for 11 days. In mmol, p=0.001), in conjunction with increased ACE2 enzymatic activity addition, renoprotective effect of linagliptin was examined in cultured mouse under both glycemic conditions (p≤0.006). Increases in ACE2 activity and proximal tubular (mProx) cells stimulated with FFA-bound albumin. We fi rst protein levels with EMPA did not correlate with declines in GFR, RPF or blood confi rmed that neither FFA-bound albumin injection nor linagliptin treatment pressure or increases in glucosuria, hematocrit, urea, plasma aldosterone altered systemic characteristics including body weight, fasting blood or Ang II. glucose and food intake. In SD group, FFA-bound albumin caused tubular cell In this analysis, EMPA increased urinary ACE2 excretion independent of apoptosis, interstitial infl ammation characterized by macrophage infi ltration changes in plasma and urinary glucose levels, renal parameters or blood and increased mRNA expression of infl ammatory cytokines, such as MCP- pressure. In light of the potential protective effects of ACE2-Ang-(1-7) path- 1, IL-6 and TNF-α, and interstitial fi brosis with increased expression of ways in experimental diabetes, the interaction between SGLT2 inhibition fi bronectin and PAI-1. These alterations were all prevented by the treatment and renoprotective pathways merits further study. with linagliptin. Furthermore, in cultured mProx cells, linagliptin inhibited Supported By: Boehringer Ingelheim; CIHR FFA-bound albumin-induced apoptosis and increases in mRNA expression level of infl ammatory cytokines and fi brotic markers. These results indicate 544-P that DPP-4 inhibitors exert anti-apoptotic, anti-infl ammatory and anti-fi brotic Effect of Saxagliptin on Renal Outcomes effect as an additional pleiotropic effect, and may serve as a therapeutic OFRI MOSENZON, DEEPAK L. BHATT, LEÓN LITWAK, MARINA SHESTAKOVA, GIL strategy to protect proximal tubular cells against proteinuria in patients with LEIBOWITZ, BOAZ HIRSHBERG, ARTIST PARKER, NAYYAR IQBAL, BENJAMIN M. diabetic nephropathy. SCIRICA, RONALD C. MA, ITAMAR RAZ, Jerusalem, Israel, Boston, MA, Buenos Aires, Argentina, Moscow, Russian Federation, Wilmington, DE, Princeton, NJ, Hong 546-P Kong, China Correlation between 25(OH) Vitamin D Levels and Diabetic Nephro- Renal outcomes of 16,492 patients (pts) with type 2 diabetes were pathy Progression among Japanese Type 2 Diabetes Patients prospectively followed in the SAVOR TIMI 53 trial for a median of 2.1 years. MAKI KAWASAKI, SHU MEGURO, MASUOMI TOMITA, YUSUKE KABEYA, TAKE- Predefi ned renal outcomes (safety and exploratory effi cacy) were: doubling SHI KATUKI, YOICHI OIKAWA, HENPIRU OH, AKIRA AINAI, HIDEKI HASEGAWA, of serum creatinine, initiation of chronic dialysis, renal transplant, serum HIROSHI ITOH, AKIRA SHIMADA, Tokyo, Japan creatinine>6.0 mg/dl, reduction from baseline of albumin/creatinine ratio Previous studies have reported that 25 (OH) vitamin D defi ciency has been (ACR) and categorical changes in ACR. associated with CKD progression and patients with low 25(OH) vitamin D Pts were stratifi ed by renal dysfunction (RD) as normal/mild (eGFR >50 levels had a higher risk of all-cause mortality despite adjustments for CKD mL/min; N=13,916), moderate (eGFR 30-50 mL/min; N=2,240) or severe RD stage in Caucacian population. However, no study has evaluated in Asian (eGFR <30 mL/min; N=336). Baseline ACR was normal (ACR<30 mg/G) in population. The aim of the study was to assess the correlation between 9,696 (58.8%) pts, microalbuminuria (ACR 30-300 mg/G) in 4,426 (26.8%) pts 25(OH) vitamin D levels and diabetic nephropathy progression in Japanese. and macroalbuminuria (ACR >300 mg/G) in 1,638 (9.9%) pts. We examined 132 type 2 diabetes patients and CKD who attended our Patients assigned to saxagliptin (SAXA) vs. placebo were more likely to department from September to November 2009. Plasma 25(OH) vitamin D improve their ACR (based on categorical shifts) (11% vs. 9%, p<0.01) and levels were measured at baseline, and we followed for 3 years. The primary less likely to worsen their ACR (13% vs. 16%, p<0.01). The most prominent endpoint was a >50% increase in baseline serum creatinine, hemodialysis improvement was noted in those with microalbuminuria at baseline; initiation, or death. at 1 year 31.3% vs. 25.7% of patients with microalbuminuria reverted to Primary endpoint was reached by 2.3 person-1000 year. Primary endpoint normoalbuminuria in SAXA and placebo groups respectively (p<0.0001). were signifi cantly increased in patients with lower 25(OH) vitamin D: 0.7 These results were sustained for 2 years and at end of trial. The signifi cant person-1000 year with higher 25(OH) vitamin D, 4.2 person-1000 year improvement in categorical ACR in SAXA group at 2 years was similar in with lower 25(OH) vitamin D (p value for log-rank test =0.0002). In a Cox pts who had a decrease in HbA1c >0.5% at 1 year, and in those who did proportional hazard model the unadjusted HR (95%CI) was 5.9 (2.0-17.2). The not (p=0.002 vs. p=0.023, respectively). No signifi cant differences in the association persisted after adjustment for age, gender, BMI, and estimated additional predefi ned renal outcomes were noted between the SAXA and GFR (adjusted HR 4.2 (1.3-13.6)). placebo groups: doubling of serum creatinine [153 (0.92%) vs. 147 (0.89%), In Japanese subjects with type 2 diabetes, lower 25(OH) vitamin D levels HR 1.04 (0.83-1.30)], initiation of chronic dialysis, renal transplant or serum were independently associated with a higher risk of death and diabetic creatinine>6.0 mg/dl [51 (0.31%) vs. 55 (0.33%), HR 0.90 (0.61-1.32)] or nephropathy progression. composite end point of death and all of the above [573 (3.47%) vs. 525 (3.20%), HR 1.08 (0.96-1.22)]. 547-P In the SAVOR TIMI 53 trial, SAXA improved ACR and had a neutral effect Common Polymorphisms in Antioxidant Genes Are Associated with on the additional predefi ned renal outcomes. Preliminary data suggest Diabetic Nephropathy and End Stage Kidney Failure in Slovenian saxagliptin’s effect on ACR might be independent of its effect on glucose Type 2 Diabetes Patients control. JASNA KLEN, KATJA GORICAR, ANDREJ JANEZ, VITA DOLZAN, Trbovlje, Sloven- Supported By: AstraZeneca/Bristol-Myers Squibb ia, Ljubljana, Slovenia Genetic factors may also play an important role in the risk for diabetic complications in type 2 diabetes (T2D) patients. The aim of our study was to investigate the role of common polymorphisms in genes coding for antioxidative enzymes on the risk for macro and microvascular complications in T2D. Patients with T2D who attended the outpatient clinic at the General Hospital Trbovlje, Slovenia were included in the study. All patients were

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A140 COMPLICATIONS—NEPHROPATHY—CLINICAL AND TRANSLATIONAL RESEARCH clinically and biochemically well characterised and genotyped for SOD2, CAT, Body weight (kg) GPX, GSTP1,GSTM1, GSTT1, GCLM and GCLC. Risk for diabetic complications Baseline 72.2 (15.6) 73.8 (15.1) was assessed using logistic regression. Change from baseline 0.2 (3.9) 0.0 (3.7) In total 181 patients with a median duration of T2D 11 (25-75 % range Insulin dose, (U/kg/day) 6-17) years were divided in two groups: patients on hemodialysis due to end Pre-study 0.58 (0.36) 0.55 (0.29) stage renal failure (N = 25) and patients without end stage renal failure (N = Baseline 0.47 (0.28) 0.44 (0.24) 156). Both groups differed only marginally regarding HbA1c levels (p=0.049). Week 24 0.54 (0.32) 0.51 (0.27) After adjustment for duration of T2D and HbA1c, CAT rs1001179 and GSTP1 Creatinine (µmol/l) POSTERS rs1138272 showed strongest association with the risk for end stage kidney Baseline 113.2 (59.9) 80.2 (32.0) Complications failure (p = 0.017 and p = 0.032, respectively). CAT rs1001179 signifi cantly Change from baseline −12.9 (32.9)* −3.7 (24.5)* Acute and Chronic infl uenced eGF stage (p = 0.032), while GSTP1 rs1695 and GSTP1 haplotypes Triglycerides (mmol/l) infl uenced the risk of moderately increased albuminuria (p = 0.024 and p = Baseline 2.2 (1.1) 2.1 (1.1) 0.014, respectively). No association was observed between the investigated Change from baseline −0.3 (0.8)* −0.3 (0.9)* polymorphisms and other microvascular and macrovascular diabetic SBP (mmHg) complications. Baseline 142.7 (21.9) 134.1 (18.0) Our results suggest that genetically determined capacity for defence Change from baseline −8.5 (21.1)* −6.2 (17.2)* against oxidative stress may play a role in the pathogenesis of diabetic All values are mean (SD); *p<0.05. nephropathy and end stage kidney failure. Common functional polymorphisms FPG, fasting plasma glucose; PPG, postprandial plasma glucose; SBP, systolic blood pressure. in CAT and GSTP1 genes could be used as independent genetic markers for identifi cation of individuals with T2D at an increased risk for developing end stage kidney failure. 549-P Diabetic Cardiovascular Autonomic Neuropathy Predicts New- Supported By: ARRS (P1-0170, P3-0298) Onset of Chronic Kidney Disease in Patients with Type 2 Diabetes Mellitus: A Ten-Year Follow-up Study 548-P SEUNG-HYUN KO, JAE-SEUNG YUN, HYE-SOO KIM KIM, KI-HO SONG, YONG- Safety and Effectiveness of Insulin Analogs in People with Type 2 MOON PARK, YU-BAE AHN, Suwon, Republic of Korea, Seoul, Republic of Korea, Diabetes and End-Stage Renal Disease in the A1chieve Study Columbia, SC INES KHOCHTALI, MOHAMED E. KHAMSEH, OLUFEMI A. FASANMADE, JIAN- We investigated factors that might infl uence the development of chronic WEN CHEN, ISSAM M. HAJJAJI, Monastir, Tunisia, Tehran, Islamic Republic of kidney disease (CKD) in patients with type 2 diabetes. From January 2003 Iran, Lagos, Nigeria, Zurich, Switzerland, Tripoli, Libyan Arab Jamahiriya to December 2004, a total of 1,013 patients with type 2 diabetes without A1chieve was a 24-week non-interventional study evaluating insulin CKD (estimated glomerular fi ltration rate [eGFR] ≥ 60 ml/min/1.73m2) were analogs in 28 countries of 66,726 people with type 2 diabetes who had consecutively enrolled. The estimated GFR was measured annually, and new started insulin detemir, insulin aspart or biphasic insulin aspart 30 in the 4 onset CKD was defi ned as eGFR < 60 ml/min/1.73m2 using a Modifi cation weeks prior to entry. This analysis investigated outcomes in people with/ of the Diet in Renal Disease formula. A cardiovascular autonomic function without end-stage renal disease (ESRD) (n=647 and n=56,505, respectively). test (AFT) was performed to diagnose cardiovascular autonomic neuropathy At baseline, 11.3%, 10.7% and 49.1% of those with ESRD, and 5.9%. (CAN) using heart rate variability parameters. We used a Cox proportional 6.6% and 59.9% of those without ESRD were treated with aspart, basal hazard regression analysis to test associations between new onset CKD insulin+aspart or biphasic insulin aspart 30, respectively. In both groups, and potential explanatory variables. The median follow-up time was 10.0 glycemic control improved after 24 weeks (HbA1c, fasting plasma glucose and years. The mean age was 55.6 ± 10.8 years, and the duration of diabetes postprandial plasma glucose reduced signifi cantly from baseline [p<0.001] was 8.3 ± 7.0 years. The baseline eGFR was 98.7 ± 26.3 ml/min/1.73m2. in both groups) (Table). Overall hypoglycemia decreased from 8.02 to 1.62 The patients in the CKD group were older (P < 0.001), had hypertension (P < events/person-year from baseline to week 24 in those with ESRD and from 0.001), a longer duration of diabetes (P < 0.001), higher baseline A1C levels 3.25 to 1.77 in those without ESRD. Major hypoglycemia decreased from (P < 0.001), higher rates of albuminuria (P < 0.001), and received more insulin 1.87 to 0.000 events/person-year in those with ESRD and from 1.77 to 0.007 and ACE inhibitor treatment (P < 0.001). A Cox hazard regression analysis in those without ESRD. Triglycerides and systolic blood pressure decreased revealed that the development of CKD was signifi cantly associated with the signifi cantly (p<0.001) in both groups. There was no signifi cant change in presence of cardiovascular autonomic dysfunction (normal vs. early CAN, HR body weight. In the A1chieve study, insulin analog therapy was associated 1.86, 95% CI 1.01 - 3.42; P = 0.041; normal vs. defi nite CAN, HR 4.45, 95% CI with improved glycemic control and reduced risk of hypoglycemia in people 2.53 - 7.81; P < 0.001) after adjusting for sex, age, diabetic duration, mean with type 2 diabetes with and without ESRD after 24 weeks of treatment. A1C, albuminuria, treatment of insulin and ACE inhibitor/ARB. In conclusion, Clinical Outcomes After 24 Weeks of Treatment with Insulin Analogs. the development of CKD from normal renal function was independently End-stage No end-stage associated with cardiovascular autonomic dysfunction in patients with type renal disease renal disease 2 diabetes. (n=647) (n=56,505)

HbA1c (%) 550-P Baseline 9.4 (2.1) 9.5 (1.8) Comparison of Estimated Glomerular Filtration Rate (GFR) vs. Change from baseline −1.9 (2.0)* −2.1 (1.7)* Measured GFR in Patients with Type 2 Diabetes (T2DM) over an FPG (mg/dl) 8-Year Period Baseline 184.5 (74.6) 195.0 (63.6) ANNA J. WOOD, NAYOMI PERERA, LEONID CHURILOV, DAVID THOMAS, Change from baseline −55.5 (75.2)* −67.8 (63.5)* AURORA POON, RICHARD J. MACISAAC, GEORGE JERUMS, ELIF I. EKINCI, Mel- FPG (mmol/l) bourne, Australia Baseline 10.2 (4.1) 10.8 (3.5) Serum creatinine based equations are routinely used to assess renal Change from baseline −3.1 (4.2)* −3.8 (3.5)* function, however, the use of these equations in diabetes has recently come PPG (mg/dl) under scrutiny. We aimed to assess the performance of the Chronic Kidney Baseline 252.7 (88.8) 268.6 (80.6) Disease Epidemiology Collaboration (CKD-EPI) equation for estimating Change from baseline −78.9 (92.9)* −95.5 (81.6)* glomerular fi ltration rate (eGFR). Adults with T2DM (n=152) who had two PPG (mmol/l) measurements of GFR (mGFR) using the plasma disappearance of DTPA Baseline 14.0 (4.9) 14.9 (4.5) (diethylene-triamine-penta-acetic acid) at baseline and at eight years from Change from baseline −4.4 (5.2)* −5.3 (4.5)* baseline were included. The agreement between mGFR and eGFR was Overall hypoglycemia, events/patient-year estimated using Lin’s Concordance Coeffi cient (LCC) and validated using Baseline 8.02 3.25 Reduced Major Axis Regression (RMAR). At baseline (median mGFR: 95.4ml/ Week 24 1.62 1.77 min/1.73m2, IQR: 77.1 to 108.5), there was moderate agreement between Major hypoglycemia, events/patient-year mGFR and eGFR: Lin’s CC=0.59 (95%CI: 0.51, 0.67), RMAR slope=0.72, Baseline 1.87 1.77 intercept=12.1 (Figure, panel A). After 8 years (median mGFR: 64.9ml/ Week 24 0.000 0.007 min/1.73m2, IQR: 52.4 to 84.2), the agreement improved: LCC=0.82 (95%CI: 0.77, 0.87), RMAR slope=0.83, intercept=8.5 (Figure, panel B). At both time

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A141 COMPLICATIONS—NEPHROPATHY—CLINICAL AND TRANSLATIONAL RESEARCH

points, the difference between mGFR and eGFR increased proportionally to Odds Ratio of Albuminuria by Vitamin D Categories. the magnitude of the GFR, indicative of proportional bias. This study showed Vitamin D Unadjusted OR Model 2 OR Model 3 OR that in T2DM, the CKD-EPI equation underestimated GFR at high normal/ (ng/mL) (95% CI) [age, sex, race, [Model 2 plus diabetes normal renal function with better performance in mild/moderate reduction height/weight] and hypertension] of renal function. (95% CI) (95% CI) 0-10 0.71 (0.5-1.00) 1.12 (0.74-1.71) 1.17 (0.76-1.80) 10-20 0.76(0.55-1.04) 0.93 (0.66-1.31) 1.00 (0.72-1.40) POSTERS

Complications 20-30 0.84 (0.61-1.16) 0.87 (0.62-1.20) 0.86 (0.62-1.19) Acute and Chronic 30-40 1 (ref) 1 (ref) 1 (ref) 40-50 1.14 (0.67-1.96) 1.13 (0.66-1.94) 0.89 (0.48-1.66) ≥ 50 1.26 (0.58-2.76) 1.40 (0.63-3.12) 1.60 (0.73-3.48) P-value 0.04 0.47 0.40 Supported By: Seattle Children’s Center

553-P 551-P Once-Daily ZS-9, a Novel Selective Potassium Trap, Maintained Changes in Albuminuria in Type 2 Diabetes Patients: A Five-Year Normokalemia in Patients with Diabetes after Acute Therapy for Follow-up at Diabetes Clinics in Japan Hyperkalemia YUKO WATANABE, MIYUKI NOGAWA, NOBUAKI KAWAGOE, HITOMI FUJII, HENRIK S. RASMUSSEN, GEOFFREY A. BLOCK, PHILIP T. LAVIN, MOHAMED A. TAKAICHI MIYAKAWA, Tama, Japan EL-SHAHAWY, SIMON D. ROGER, DAVID K. PACKHAM, ALEX YANG, BHUPINDER We conducted a 5-year observational cohort study to reveal changes in SINGH, Coppell, TX, Denver, CO, Framingham, MA, Los Angeles, CA, Gosford, albuminuria and factors related to remission and/or progression. A total of Australia, Reservoir, Australia, Belmont, CA, Tempe, AZ 151 consecutive adult type 2 diabetic patients seen at three clinics in Tokyo Hyperkalemia is a serious, common fi nding in patients with diabetes were enrolled in 2007. Eligible patients had spot urine albumin to creatinine mellitus and limits use of life-saving renin-angiotensin-aldosterone system ratio (ACR) measured by immunoturbidimetric assay at least two times in (RAAS) inhibitors. ZS-9 is a novel, nonabsorbed cation exchanger designed to each year. An estimated glomerular fi ltration rate (eGFR) was calculated by specifi cally entrap excess potassium (K+). A Phase 3 multicenter, randomized the 3-variable Japanese equation. We excluded patients with kidney failure. double-blind, placebo-controlled trial assessed ZS-9 for acute treatment of Patients had a mean age (SD), 59.3 (10.6); female, 43%; mean BMI, 24.7 kg/ hyperkalemia followed by maintenance of normokalemia. Here we present m2 (4.2); mean HbA1c, 7.63% (1.27); eGFR 82 ml/min/1.72m2 (22); and ACR maintenance-phase results in the prespecifi ed subgroup with diabetes mellitus. 45.2 mg/g creatinine (118.3). 28% of patients were on oral antidiabetic agents Patients (N=753) with serum K+ 5-6.5 mEq/L were randomized (1:1:1:1:1) to ZS-9 and/or insulin; 26% of patients were on angiotensin receptor blockers (ARBs). (1.25g, 2.5g, 5g or 10g) or placebo three times daily (TID) for 48 hours (acute Albuminuria categories were labeled as follows; normoalbuminuria, A1; phase), after which those with K+ ≤4.9 mEq/L were re-randomized to ZS-9 or microalbuminuria, A2; and macroalbuminuria, A3. We then divided patients placebo once daily for Day 3-15 (maintenance phase). The maintenance-phase into six developmental patterns of ACR as follows (ACR at start/5 year later, primary effi cacy endpoint was the difference in the rate of K+ change over Day % of patients): A1/A1, 55%; A2/A2, 12%; A3/A3, 2%; A2/A1, 8.6%; A1/A2, 16%, 3-15 vs. placebo, using longitudinal modeling of the slope to account for all and A2/A3, 6%. There was no signifi cant difference in age, sex, BMI, duration post-baseline K+ data. At baseline, mean K+ was 5.3 mEq/L; 60% of patients of diabetes, eGFR, diabetic treatment, lipid profi le, blood pressure, ARBs and had diabetes and 65% were on RAAS inhibitors. Overall 542 (72%) entered the statin use in 6 groups. After excluding A3/A3 group, regression of ACR (A2/A1) maintenance phase, 42% of whom had diabetes. Consistent with the overall was signifi cantly associated with high HbA1c at start and grater improvement population, in the diabetes subgroup the maintenance-phase primary effi cacy of HbA1c at 5 year (8.65% and -1.5%, respectively; P<0.05), and they tended to endpoint was met for ZS-9 5g and 10g once daily (p<0.0001 vs. placebo), be younger and use more insulin and statins at start, had less retinopathy in 5 indicating that normokalemia was maintained vs. placebo through Day 15. In years. Patients with progression of ACR (A1/A2 and A2/A3) tended to be older, conclusion, ZS-9 5g and 10g maintained normokalemia when given once daily had lower BMI and HbA1c at start. Both progression and regression of ACR in patients with diabetes after acute treatment with ZS-9 TID for hyperkalemia. were associated with increased ARBs use in 5 years (P<0.05). Conclusions: ZS-9 may become an important therapy to maintain normokalemia and By treating diabetes and its consequences vigorously, 55% of them remained potentially optimize use of critical RAAS inhibitors in patients with diabetes. normoalbuminuric. Regression to normoalbuminuria occurred in 9% of the Supported By: ZS Pharma, Inc. patients, who were protected from retinopathy as well. 554-P 552-P Evolution of Albuminuria and the Effect of GLP-1 Agonists on Its Role of Vitamin D Defi ciency on Albuminuria in Children Progression in Type 2 Diabetes DEBIKA NANDI-MUNSHI, CATHERINE PIHOKER, KATHRYN WHITLOCK, MARYAM AKSHATA DESAI, MANISHA GARG, SIMMANJEET MANGAT, GARIMA THAPAR, AFKARIAN, Seattle, WA RUJUTA KATKAR, ADITYA MEHTA, NAVEN KANG, SANDEEP DHINDSA, AJAY Diabetic kidney disease (DKD) is a leading cause of morbidity and mortality. CHAUDHURI, PARESH DANDONA, Buffalo, NY Albuminuria is an early marker of kidney disease in childhood. Correlation of Albuminuria is an indicator of glomerular and endothelial damage in patients increased albuminuria with lower Vitamin D levels was seen in a large cohort of with diabetes mellitus. We compared the evolution of albuminuria in patients adults, but has not been studied in the pediatric population. If this association at our center (DECWNY) over 2.3 years with that from the largest database is true, Vitamin D therapy may be a safe adjunct in treatment of DKD. on albuminuria derived from Internal medicine and Endocrinology practices National Health and Nutrition Examination Survey (2001-6) data was in the Kaiser Permanente Health System (KPHS) over a 5.4 year follow up. In obtained for 8789 subjects (ages 6-19 yrs.) including serum 25-hydroxyvitamin addition, we hypothesized that the use of GLP-1 agonists resulted in a greater D (Vit D), urine albumin excretion and relevant covariates (Table). Vit D was regression in micro-albuminuria than that in non-users of GLP-1 agonists. evaluated as a categorical variable. Albuminuria was evaluated as a binary Comparison of evolution of albuminuria between the centers expressed as variable, defi ned as an albumin: creatinine ratio (ACR) > 17 mg/g for boys and percentages with per annum(pa) progression rates included in parenthesis. >25 mg/g for girls. Logistic regression was used to examine cross-sectional association between Vit D and albuminuria. The cohort consisted of 50% Cohorts Center Normal Micro- Macro- ESRD P value girls and 27% non-Hispanic Whites. Hypertension was seen in 2.7%, 36% albuminuria albuminuria were overweight/obese, and 0.5% had diabetes. There was no association Baseline normal KPHS 53.6 40(7.4 pa) 6.3(1.1 pa) 0.08(0.01 pa) P=0.0003 between Vit D and ACR in unadjusted or adjusted models (Table). This held 100%/0/0/0 DECWNY 86.7 13(5.6 pa) 0.3(0.13 pa) 0 true when ACR was analyzed as a continuous variable, although there was a Baseline microalbuminuria KPHS 20(3.7 pa) 59.7 20(3.7 pa) 0.3(0.05 pa) P=0.0001 trend for higher albuminuria in those with lower Vit D levels. Contrary to the robust association between Vit D and albuminuria in 0/100%/0/0 DECWNY 57(24.7 pa) 37 6(2.6 pa) 0 adults, in children and adolescents 25-hydroxyvitamin D is not associated Baseline macroalbuminuria KPHS 0 33.4(6.2 pa) 62.3 4.3(0.8 pa) P<0.0001 with increased albumin excretion. 0/0/100%/0 DECWNY 37(16 pa) 24(10.4 pa) 39 0

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A142 COMPLICATIONS—NEPHROPATHY—CLINICAL AND TRANSLATIONAL RESEARCH

The use of GLP-1 agonists resulted in regression of microalbuminuria to 557-P normoalbuminuria in 67%(38% pa) with no progression to macroalbuminuria; Endothelial Cell Activity in the Immunoglobulin G Fraction of Plasma as compared to 42% regression to normal (25% pa) with 11% progression to Differentially Predicts Progression of Renal Insuffi ciency, End macroalbuminuria in the non GLP users( 6% pa) (p<0.0001). Stage Renal Failure, or Death in Diabetic Nephropathy Participants The differences in the evolution of albuminuria between KPHS and our from the VA Nephron-D Having Lower vs. Higher Baseline Level of center are highly signifi cant and demonstrate that albuminuria can be Albuminuria reversed by aggressive control of glycaemia, blood pressure, dyslipidemia MARK ZIMERING, JANE ZHANG, DORIA NARIVELY, SUSANNAH CHIU, NICHOLAS and the use of RAAS inhibitors. Furthermore, GLP-1 agonists are associated

EMANUELE, LINDA FRIED, VA NEPHRON D INVESTIGATORS, East Orange, NJ, POSTERS with a signifi cant decrease in the progression of microalbuminuria, also with West Haven, CT, Lyons, NJ, Hines, IL, Pittsburgh, PA Complications a signifi cantly greater reversal to normoalbuminuria with no progression to Diabetic nephropathy (DN) is a leading cause of end stage renal disease Acute and Chronic macroalbuminuria. (ESRD) and cardiovascular mortality in adult type 2 diabetes mellitus (T2DM). In our prior work, endothelial cell (EC) inhibitory IgG autoantibodies 555-P (AA) predicted an increased risk of diabetic retinopathy (DR) and (possible) Comparison of Statins on Kidney Function in Patients with Type 2 progression to DN. We evaluated whether inhibitory EC AA was associated Diabetes with the hazard rate of primary endpoint, a substantial decline in estimated KO HANAI, TETSUYA BABAZONO, YASUKO UCHIGATA, Tokyo, Japan glomerular fi ltration rate, ESRD or death, in the VA Nephron D study, a Recent studies suggest that statins may have renoprotective properties; randomized study comparing angiotensin receptor blocker (ARB) or dual however, whether there are differences among statins in their effectiveness ARB plus angiotensin converting enzyme inhibitor therapy in T2DM having against progression of diabetic kidney disease remains controversial. proteinuric DN. Calf pulmonary artery EC (M199, 10% FCS) were incubated Furthermore, the durations of follow-up in previous studies were relatively (at 37 C x 48 hrs) with (30 ug/mL) of the protein A eluate of plasma in a random short, all within 1 year. Here, we examined the comparative effectiveness sample of 305 individuals with biorepository samples at randomization. of statins on kidney function in a long-term follow-up study of diabetic Antibody level = proportion of surviving EC compared to cells without test patients. IgG (100%). We observed 38% (117/305) strongly inhibitory EC activity (< This was a single-center historical observational longitudinal cohort study. 80%) in the IgG fraction of plasma in DN population. Strongly inhibitory We enrolled 326 ambulatory patients with type 2 diabetes (mean [± SD] age: EC AA activity (i.e. < 80%) was signifi cantly associated with baseline 60 ± 11 years, men: 61.3%) who were newly prescribed one of the following prevalence of DR (laser or vitrectomy) (53% vs. 40%, p =.025) and inversely 4 statins: pravastatin, rosuvastatin, atorvastatin and pitavastatin, and who with cardiovascular disease (53% vs. 65%, p = 0.039). Fifty-eight primary had estimated glomerular fi ltration rate (eGFR) level of ≥ 30 mL/ min/ 1.73 endpoints were experienced by 305 subjects. In Cox regression analysis, m2 during the period between April 2006 and June 2010. To adjust for the there is a signifi cant interaction effect of antibody and albuminuria (< 1 g/g effects of confounding factors, we used the standardized inverse probability creat vs. >= 1 g/g creat) (p=.005) where antibody level was a signifi cant of treatment weighted (IPTW) method based on the propensity score, which predictor of primary events (HR 26.1, 95% CI 1.3-507.1, p=0.031) among was estimated using 19 risk factors. The outcome measurement was the subjects with baseline albumin/creatinine ratio (ACR) >= 1g/g creatinine, annual decline in eGFR. but not among subjects with baseline ACR <1g/g creatinine (HR 0.04, The median follow-up period was 4.3 years (range, 3.0 - 7.1 years). The 95% CI 0.01-2.0, p=0.11). These data suggest role(s) for EC AA in DN and mean (± standard error) annual eGFR decline in patients treated with complications. pravastatin (0.9 ± 0.3 mL/min/1.73 m2/year) was signifi cantly slower than Supported By: U.S. Dept. of Veterans Affairs; Merck & Co., Inc. that in patients treated with rosuvastatin (2.0 ± 0.3 mL/min/1.73 m2/year, P= 0.005), atorvastatin (2.2 ± 0.3 mL/min/1.73 m2/year, P= 0.002) and 558-P pitavastatin (2.0 ± 0.3 mL/min/1.73 m2/year, P= 0.009). In an analysis using Age at Type 1 Diabetes (T1D) Onset and Complication Incidence the IPTW method, patients treated with pravastatin also had a signifi cantly Over 20 Years of Follow-up slower eGFR decline (0.8 ± 0.3 mL/min/1.73 m2/year) than those treated with TINA COSTACOU, TREVOR J. ORCHARD, Pittsburgh, PA rosuvastatin (1.8 ± 0.3 mL/min/1.73 m2/year, P= 0.012), atorvastatin (1.9 ± We have previously reported that the male excess of T1D kidney disease 0.3 mL/min/1.73 m2/ year, P= 0.004) and pitavastatin (2.3 ± 0.7 mL/min/1.73 cases in the 1950-64 diagnosis cohort has been eliminated in the 1965-70 m2/year, P= 0.040). cohort, where incidence was slightly higher in women. Given recent data of Pravastatin may be superior to rosuvastatin, atorvastatin, and pitavastatin a greater incidence in men vs. women with an age at onset (AON) >10 yrs, we in preserving kidney function in type 2 diabetic patients. assessed sex differences in complication incidence by AON. We used data from the Epidemiology of Diabetes Complications study of childhood onset 556-P T1D (mean baseline age 28, and duration 19, yrs). Analyses were restricted Decreased Plasma α-klotho Predict Progression of Nephropathy to those diagnosed with T1D >1965 to reduce potential survival bias (n=434). with Type 2 Diabetic Patients Proliferative retinopathy, confi rmed distal symmetric polyneuropathy, micro- SU BIN PARK, SANG SOO KIM, IN JOO KIM, BO HYUN KIM, YUN KYUNG JEON, and macro-albuminuria, renal failure (RF), coronary artery disease (CAD) and WON JIN KIM, YOON JEONG NAM, KANG HEE AHN, JONG HO KIM, SEONG SU mortality were assessed over 20 yrs of follow-up. AON was dichotomized MOON, YONG KI KIM, Busan, Republic of Korea, Gyeongju, Republic of Korea as in the previous report (< or >10 yrs). Univariately, no sex differences were The potential role of soluble α-klotho in diabetic kidney disease has not observed by AON, with the exception of a higher CAD incidence in men vs. yet been evaluated. The aim of this study was to evaluate the association women (16.5% vs. 8.6%, p=0.06) with AON <10. Though not statistically of plasma and/or urine α-klotho with the progression of type 2 diabetic signifi cant, women had a higher RF incidence than men (16% vs. 9%, nephropathy. The baseline values of plasma and urine α-klotho were p=0.16) with AON >10 yrs (Fig 1). In Cox models, no signifi cant interaction measured in 147 patients with type 2 diabetes mellitus and 25 non-diabetic was observed between sex and AON. Our results suggest deviations in the controls with estimated glomerular fi ltration rate (eGFR) ≥60 mL/min/1.73 m2. presentation of T1D complications from European cohorts, where women In this prospective observational study, a total of 111 type 2 diabetic patients appear to enjoy protection from kidney disease compared to men in those were followed up for 26 months (8-45 months). Plasma and urine α-klotho diagnosed with T1D after 10 yrs. levels were signifi cantly higher in diabetic patients than non-diabetic controls at baseline. Among diabetic patients, plasma α-klotho concentration was inversely associated with stages according to albuminuria (P for trend 0.008), although urinary α-klotho levels were stable and did not change with increasing urinary albumin excretion. Plasma α-klotho, but not urine α-klotho, was negatively correlated with the decline of eGFR (r = -0.245, P = 0.009; r = -0.015, P = 0.921, respectively). After adjusting for several clinical parameters, plasma α-klotho was signifi cantly associated with the decline of eGFR (r = -0.215, P = 0.018). In a multivariate analysis, the lowest tertile of plasma α-klotho showed a signifi cant association with the progression of albuminuria (HR, 2.34; 95% CI, 1.12-3.25; P = 0.035). In conclusions, the disappearance of compensatory increase of plasma α-klotho might be predictive marker for progression of type 2 diabetic nephropathy. Supported By: DK034818-21

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A143 COMPLICATIONS—NEUROPATHY

559-P exposure to dysglycaemia may not cause thalamic changes. Central nervous ABCC9 Variant Is Associated with a Reduced Risk of Micro- system effects measured in earlier studies may be transitory fi ndings or albuminuria (MA) in Type 1 Diabetes (T1D) with Long-term Follow- related to micro or macrovascular complications. up: The Pittsburgh Epidemiology of Diabetes Complications (EDC) Supported By: EFSD Study RACHEL G. MILLER, YUEFANG CHANG, TREVOR J. ORCHARD, ROBERT E. & 561-P FERRELL, TINA COSTACOU, KEVIN HO, Pittsburgh, PA Gene Expression Analyses of Sciatic Nerve from BTBR ob/ob Mice,

POSTERS Vascular smooth muscle (VSM) ATP-sensitive potassium (KATP) channels a Novel Model of Diabetic Neuropathy, Implicate an Association of Complications (pharmacologically distinct from but related to sulfonylurea-sensitive Infl ammation with Neuropathy Onset Acute and Chronic pancreatic -cell KATP channels regulating insulin secretion) bridge membrane PHILLIPE D. O’BRIEN, JUNGUK HUR, JOHN M. HAYES, EVA L. FELDMAN, Ann excitability and cellular metabolism by regulating vascular tone in response Arbor, MI to changes in intracellular ATP concentration resulting from glucose Given the lack of treatments for diabetic neuropathy (DN), a common metabolism. We tested whether a VSM-KATP channel gene polymorphism diabetic complication, accurate disease models are necessary. Characteriza- in the sulfonylurea receptor 2 gene (SUR2) ABCC9 rs17335932 is associated tion of the leptin-defi cient BTBR ob/ob mouse, a type 2 diabetes model, with incidence of MA in a cohort with T1D with long-term follow-up. demonstrated that the mice develop robust diabetes coincident with severe Data on rs17335932 a functional promoter region polymorphism was neuropathic features. These features include nerve conduction defi cits available in 483 participants from the EDC Study. At baseline 268 individuals and intraepidermal nerve fi ber loss by 9 and 13 weeks of age, respectively, were free of MA; these were followed prospectively for 22 yrs to determine supporting its use as a DN model. To gain insight into DN mechanisms, we MA incidence. MA was defi ned as an albumin excretion rate of ≥20 µg/min. performed microarray analysis on sciatic nerve from BTBR ob/ob mice which Alternate analyses were performed for incidence of persistent MA defi ned identifi ed 1,465 and 632 differentially expressed genes associated with as 2 consecutive biennial clinic visits with MA or worse renal status. diabetes at 5 and 13 weeks, respectively. Of these genes, MMP12 was found Of those with the AG genotype (n=18) 11.1% developed incident MA vs. to be the most highly upregulated transcript, with signifi cantly increased 42.8% of the AA genotype (n=250) (p=0.01). No GG genotypes were observed. protein levels also being confi rmed at these time points. Further analyses A Cox proportional hazards model adjusting for potential confounders at identifi ed overrepresentation of infl ammation and immune-related functions baseline yielded hazard ratio=0.16 (95% CI: 0.04-0.66; p=0.01). In alternate in BTBR ob/ob mice, which interestingly were more highly represented at analyses for persistent MA 0 individuals with AG genotype developed 5 weeks, suggesting a role in DN onset. To complement gene expression persistent MA vs. 16.4% of AA (p=0.06). End-stage renal disease and total analysis, we demonstrate that protein levels of select cytokines, including mortality were also examined; while neither reached statistical signifi cance IL-10, Eotaxin/CCL11, KC/CXCL1 and IP10/CXCL10, were signifi cantly (p=0.34 and 0.16, respectively) the survival curves by genotype appeared to overexpressed at 13 weeks in BTBR ob/ob mouse SCN. Furthermore, we separate at approximately 15 yrs of follow-up. Two genotypes of a second compared our array data to that from an established DN model, the C57BKS promoter region polymorphism rs35677639 were also associated with an db/db mouse, which refl ected a common dysregulation of infl ammatory altered MA incidence. and immune-related pathways. Together, our data demonstrate that BTBR These apparent associations of two ABCC9 promoter region poly- ob/ob mice develop rapid and robust DN associated with dysregulated morphisms and MA incidence should be validated in other longitudinal T1D infl ammation and immune-related processes. populations. Supported By: ADA (7-12-BS-045); NIH (1DP3DK094292, 1R24082841); JDRF Supported By: NIH/NIDDK (R01DK034818) & 562-P COMPLICATIONS—NEUROPATHY Effi cacy of DS-5565 in Diabetic Peripheral Neuropathic Pain: Pain Assessment and Correlations with a Numerical Rating Scale and Visual Analog Scale DOMENICO MERANTÈ, UMA SHARMA, KAREN FEINS, CHING HSU, AARON Guided Audio Tour: The Skin, the Cornea, the Heart, and the Brain (Posters: I. VINIK, INVESTIGATORS ON BEHALF OF THE DS-5565-A-U201 U.S. PHASE II 560-P to 567-P), see page 13. STUDY, Gerrards Cross, United Kingdom, Canton, MI, Edison, NJ, Parsippany, NJ, Norfolk, VA & 560-P Up to 26% of all patients with diabetic peripheral neuropathy experience Dysglycaemic Thalamic Damage After Long Duration of Diabetes neuropathic pain, often with insuffi cient pain relief. DS-5565, a new potent, MARNI GREIG, DINESH SELVARAJAH, PALLAI SHILLO, SOLOMON TESFAYE, IAIN selective alpha2-delta ligand, is being investigated in a randomized, double- WILKINSON, Sheffi eld, United Kingdom blind, placebo- and active comparator-controlled phase 2 study in diabetic Proton Magnetic Resonance spectra (1 H-MRS) have been used as peripheral neuropathic pain (DPNP). The primary end point was weekly a biomarker of structural and functional damage to the brain. Previous change in average daily pain score (ADPS) for DS-5565 versus placebo from 1H-MRS studies in diabetic subjects suggest differences in exposure of brain baseline to week 5; recorded using an 11-point numerical rating scale (NRS; structures to elevated glucose levels and specifi cally to glucose handling 0 [no pain] to 10 [worst possible pain]). A pain visual analog scale (VAS) was abnormalities and decreased choline levels in the thalamus. The thalamus completed weekly; patients rate pain intensity on a 100 mm-long horizontal is an important sensory relay station and MR spectra have been reported to line (0 mm [no pain] to 100 mm [worst possible pain]). 452 DPNP patients be abnormal in subjects with diabetic neuropathic pain .The thalamus may were randomized to DS-5565 (5 mg qd, 10 mg qd, 15 mg qd, 10 mg bid, 15 mg undergo atrophy in young adults with type 1 diabetes and poor control, in bid), placebo, or pregabalin (PGB; 150 mg bid) for 5 weeks. Mean (SD) age the absence of neuropathy. Therefore there may be differences between was 60.1 (9.26) years and 53.5% were male. Majority (75%) of patients were thalamic spectra of healthy volunteers and subjects with long duration type white; remaining patients were mostly black or African-American; 15.9% 1 diabetes. were Hispanic or Latino. 91.8% of patients had type 2 diabetes; 8.2% had Methods: 1H-MRS examination at 3T (Ingenia, Phillips Netherlands) was type 1 diabetes. Duration of DPNP was 5.8 years. No signifi cant differences performed on 9 healthy volunteers (HV) and 5 subjects with diabetes (DM) were seen in HbA1c with treatment. Demographic parameters were similar and no micro or macrovascular complications. Single voxel spectra were across treatment groups. Mean changes in ADPS as measured by NRS from obtained from a 2.25cm3 (15x10x15mm) cubic volume of interest within the baseline to week 5 for DS-5565 5 mg qd, 10 mg qd, 15 mg qd, 10 mg bid, left thalamus, TE 135ms, TR 1600ms, NSA=256 using point resolved (PRESS) 15 mg bid, placebo, and PGB, were -2.04, -2.32, -2.66, -2.64, -2.79, -1.86, technique. Fitted metabolite area ratios were calculated for choline (Cho) at and -1.79, respectively (P <.05 for DS-5565 15 mg qd, 10 mg and 15 mg bid 3.2ppm, Creatine (Cr) at 3.0ppm, and N-Acetyl Aspartate (NAA) at 2.02ppm, versus placebo); as measured by VAS were -27.40, -28.56, -28.73, -25.45, (see Figure 2), and mean area under the curve values were compared. -32.82, -20.84, and -19.28, respectively (P <.05 for DS-5565 10 mg qd, 15 mg Results: DM mean age = 48.6 yr, diabetes duration,mean 31yr, mean qd, and 15 mg bid versus placebo). An exploratory analysis confi rmed that HbA1c=58mmol/mol (7.5%)HV age = 40yr. HV and DM group means for the the VAS and NRS scores were highly correlated (correlation coeffi cients of ratios were not signifi cantly different. NAA/Cr HV= 1.88 STD=0.13, DM=1.89 0.84 or higher for both placebo and all DS-5565 groups at week 5). DS-5565 STD=0.31 (p= 0.93), NAA/choline HV=0.97 STD=0.16, DM=0.97 STD=0.22 demonstrated effi cacy for treatment of DPNP as measured by either NRS (p=0.91), Cr/ Choline HV=1.98 STD=0.34 DM=1.99 STD=0.34 (p=0.96). or VAS. Discussion/Conclusion: Despite long duration of dysglycaemic exposure the healthy DM group had no difference in spectra which suggests prolonged

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A144 COMPLICATIONS—NEUROPATHY

& 563-P & 565-P Association between Mood Disorders and Cerebral Gray Matter Skin AGE/RAGE Expression Is Related to the Severity of Diabetic Atrophy in Subjects with Diabetic Peripheral Neuropathy: Implica- Neuropathy tions for Future Treatment? AHMED ALAHMAR, HASSAN FADAVI, UAZMAN ALAM, OMAR ASGHAR, DINESH SELVARAJAH, I.D. WILKINSON, M. MAXWELL, J. DAVIES, A. SANKAR, IOANNIS N. PETROPOULOS, MARYAM FERDOUSI, GEORGIOS PONIRAKIS, E. CACHIA, R. GANDHI, IRENE TRACEY, SOLOMON TESFAYE, Sheffi eld, United AISHA MESKIRI, WENDY JONES, SHAZLI AZMI, AHMAD KHEYAMI, ANDREW Kingdom, Oxford, United Kingdom MARSHALL, MITRA TAVAKOLI, ANDREW J.M. BOULTON, MARIA JEZIORSKA, POSTERS

Mood disorders are common in patients with diabetic neuropathy RAYAZ A. MALIK, Manchester, United Kingdom Complications

(DN). Using functional magnetic resonance imaging, we demonstrated Increased expression of Advanced Glycation End Products (AGE) and Acute and Chronic increased neuronal activation within brain regions involved in emotional their receptor (RAGE) have been implicated in the development of diabetic pain processing. More recently, we found increased somatosensory cortex neuropathy (DN). However, few studies have been performed in diabetic peripheral grey matter atrophy in painful and painless DN. As depression patients. has been linked to cerebral volume loss we investigated the relationship Sixty-two T1DM patients (16 with and 46 without DN) and 30 controls between brain volumes and mood disorders in DN. underwent: Nerve Conduction Studies (NCS), Vibration Perception Threshold Methods: 24 subjects with type 1 diabetes [No-DN (n=8), Painful DN (8) (VPT), Warm Threshold (WT), Corneal Nerve Fibre Density (CNFD), Fibre and Painless DN (8)] underwent detailed assessments to quantify severity Length (CNFL), Intraepidermal Nerve Fibre Density (IENFD) and AGE and of DPN [NIS(LL)+7tests]. All subjects underwent volumetric (0.8x0.8x0.8mm3 RAGE expression in foot skin biopsies. resolution) brain MRI at 3T. Images were analysed using FSL (fMRIB, Oxford). Patients with neuropathy (compared to controls & no NP) demonstrated Symptoms of depression were assessed using the Hospital Anxiety and a signifi cantly higher skin AGE expression in Epidermis (E) (2.0±0.7, 2.5±0.7, Depression Scale (HADS). 3.4±1.2, P<0.001), Microvessels (MV) (2.2±0.8, 2.4±0.7, 3.3±0.9, P<0.001), Results: Subjects with painful DN had signifi cantly greater depression Endothelium (EN) (1.9±0.7, 2.4±0.8, 2.8±0.9, P<0.01), Basement Membrane (p<0.001) scores compared to the other study groups. There was a signifi cant (BM) (2.4±0.6, 2.4±0.8, 3.3±0.9, P<0.001) and Reticular Extracellular Matrix negative correlation between both, peripheral grey matter (R=-0.43; p=0.04) (RECM) ( 3.1±0.8, 3.1±0.7, 3.8±0.8, P<0.01). Skin RAGE expression was and deep grey matter (R=-0.51; p=0.02) volumes with HADS-D scores after also increased in DN patients in E (2.7±0.9, 3.1±0.8, 3.7±0.9, P<0.001), MV adjusting for known variables (age, microvascular disease status). There was (2.4±0.9, 3.1±0.9, 3.9±0.9, P<0.001), EN (2.4±0.7, 3.1±0.9, 3.8±1.0, P<0.001), no signifi cant correlation between HADS-D score and other brain volumes BM (2.5±0.9, 3.2±0.9, 3.8±0.9, P<0.001) and RECM (2.1±0.5, 2.4±0.8, 3.1±0.8, (white matter and CSF). P<0.001). Skin AGE in E, MV, EN, BM and RECM correlated with IENFD (r=- Conclusions: We have demonstrated increased grey matter atrophy in DN 0.63, P<0.001; r=-0.59, P<0.001; r=-0.56, P<0.001; r=-0.63, P<0.001), CNFD subjects with depressive symptoms, which were most prevalent in painful DN. (r=-0.58, P<0.001; r=-0.54, P<0.001; r=-0.52, P<0.001; r=-0.43, P<0.01) Although, previous studies have reported increased brain atrophy in subjects and CNFL (r=-0.61, P<0.001; r=-0.66, P<0.001; r=-0.55, P<0.001; r= -0.52, with depression, this is the fi rst study to demonstrate this association in DN. P<0.001) respectively. Skin RAGE in E, MV, EN, BM correlated with IENFD These results may provide an explanation for intractable painful symptoms in (r=-0.52, P<0.001; r=-0.56, P<0.001; r=-0.44, P<0.01; r=-0.50 P<0.001), CNFD some patients and if confi rmed may have implications for future treatment. (r=-0.59, P<0.001; r=-0.48, P<0.001; r=-0.54, P<0.001; r=-0.44, P<0.01) and Further examination is required to explore if atrophy related to depression is CNFL (r=-0.56, P<0.001; r=-0.53, P<0.001; r=-0.52, P<0.001; r=-0.42, P<0.01) localised to regions involved in emotional pain processing. respectively. Supported By: JDRF Skin AGE/RAGE expression is increased in patients with diabetic neuropathy and correlates with small fi bre damage, providing a potential & 564-P therapeutic target for diabetic neuropathy. Diabetic Neuropathy in Patients with Latent Autoimmune Diabetes Supported By: JDRF in Adults (LADA) UAZMAN ALAM, IOANNIS N. PETROPOULOS, OMAR ASGHAR, SHAZLI AZMI, & 566-P HASSAN FADAVI, ANDREW MARSHALL, MITRA TAVAKOLI, ANDREW J.M. Prevalence and Risk Factors of Cardiovascular Autonomic Neuro- BOULTON, NATHAN EFRON, RAYAZ A. MALIK, Manchester, United Kingdom, pathy among Youth with Type 1 Diabetes: SEARCH Cohort Study Brisbane, Australia MAMTA JAISWAL, JASMIN DIVERS, SCOTT ISOM, ELAINE M. URBINA, Latent Autoimmune Diabetes in Adults is often misdiagnosed and patients LAWRENCE M. DOLAN, DANA DABELEA, GIUSEPPINA IMPERATORE, RONNY have relatively poorer glycemic control with a potential for an increased risk A. BELL, ANGELA D. LIESE, DAVID J. PETTITT, SANTICA M. MARCOVINA, of neuropathy. CATHERINE L. MARTIN, EVA L. FELDMAN, RODICA POP-BUSUI, FOR THE SEARCH Subjects with LADA (LADA) (n=19), type 2 DM (T2DM) (n=22) and non- FOR DIABETES IN YOUTH STUDY GROUP, Ann Arbor, MI, Winston-Salem, NC, diabetic healthy control subjects (C) (n=33) underwent detailed assessment Cincinnati, OH, Aurora, CO, Atlanta, GA, Columbia, SC, Santa Barbara, CA, Seattle, of neurologic defi cits (NDS), peroneal and sural nerve conduction velocity and WA amplitude (PMNCV, PMNAmp, SSNCV, SSNAmp), cold threshold (CT), warm We evaluated prevalence and correlates of Cardiovascular Autonomic threshold (WT), skin biopsy and corneal confocal microscopy to assess: nerve Neuropathy (CAN) in 1,390 youth with type 1 diabetes (T1D) with baseline fi bre density (CNFD), branch density (CNBD) and fi bre length (CNFL). and at least one follow up visit. Mean age was 17 years, duration 8 years, Comparing patients with LADA to T2DM (C vs. T2DM vs. LADA), there were A1c 9.1, 76 % non-Hispanic whites. At the follow-up visit CAN was assessed no signifi cant differences for age (49.7±12.3 vs. 50.6±11.9 vs. 56.4±6.8 years, by time and frequency domain heart rate variability (HRV) measures and P=NS), duration of diabetes (T2DM:8.7±6.5 vs. LADA:11.4±10.2 years, P=NS), categorized as possible, probable, or defi nite (presence of 1, 2 or >2 HRV lipids and blood pressure, but HbA1c was higher (38.1±3.8 vs. 55.4±8.3 vs. abnormalities). Abnormalities were defi ned by values outside the 5th or 83.4±24.7 mmol/mol, P<0.0001) and the BMI was lower (27.5±4.9 vs. 31.2±5.0 95th percentiles observed in 200 age/sex matched healthy controls from vs. 27.0±4.0 kg/m2, P=0.008). There were no signifi cant differences in the SEARCH CVD study. Comparisons across CAN groups were done by Kruskal- NDS (0.4±0.8 vs. 1.8±1.7 vs. 3.9±3.6, P=NS), PMNCV (48.6±3.7 vs. 44.5±7.3 Wallis and chi-square tests for continuous and categorical variables. We vs. 40.9±7.1 m/s, P=NS), PMNAmp (5.7±1.0 vs. 4.2±1.9 vs. 3.8±2.5 mV, P=NS), assessed glucose control over time by A1c area under the curve (AUC), which SSNCV (50.3±2.3 vs. 47.1±5.0 vs. 45.2±6.4 m/s, P=NS) and SSNAmp (18.2±7.6 summarizes the trajectory of repeated measurements of A1c over time. vs. 13.6±8.0 vs. 10.8±6.0 µV, P=NS) between LADA and T2DM. However, WT The overall prevalence of CAN was 37% (17% possible, 10% probable, (36.7±2.3 vs. 40.8±3.8 vs. 42.7±4.9 °C, P=0.008) was signifi cantly higher and 10% defi nite). Signifi cant associations for CAN were noted with older age, CT (28.6±1.8 vs. 26.7±2.9 vs. 22.8±7.0 °C, P=0.008), intra-epidermal nerve fi bre female sex, smoking, higher A1c, triglycerides and blood pressure (Table). density (IENFD) (10.6±3.0 vs. 9.1±5.1 vs. 4.4±3.7 no/mm, P=0.02), CNFD (36.8±5.4 A1c AUC was signifi cantly greater for T1D participants with CAN. vs. 28.7±10.3 vs. 24.2±5.3 no/mm2, P<0.03), CNFL (26.3±5.0 vs. 25.2±8.6 vs. In this multi-ethnic population of youth with T1D, CAN was prevalent in 19.9±4.8 mm/mm2, P=0.003), and CNBD (93.7±37.7 vs. 85.3±51.4 vs. 60.4±29.3 over 1/3 of participants, approaching estimates observed in T1D adults. no/mm2, P=0.003) were signifi cantly lower in LADA compared to T2DM. Persistent hyperglycemia, female sex and traditional CVD risk factors were Despite, comparable age, duration of diabetes and cardiovascular risk strongly associated with CAN. factors, subjects with LADA have a signifi cant small fi bre neuropathy compared to matched patients with T2DM mediated through poorer glycemic control. Supported By: JDRF

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A145 COMPLICATIONS—NEUROPATHY

64%, P<0.001). Patients with cognitive disorders had similar prevalences Characteristics of the Youth with Type 1 Diabetes by Their CAN Status. of retinopathy (30 vs. 25%; NS), nephropathy (49 vs. 47%; NS), cardiac Variable No CAN Possible CAN Probable CAN Defi nite CAN P value ischemia (33 vs. 30%; NS) and arterial disease of the lower limbs (29 vs. N=881 (63%) N= 239 (17%) N = 132 (10%) N = 138 (10%) 25%; NS), but had a higher prevalence of peripheral neuropathy (37 vs. 25%; Age, years 17 ± 4 17± 5 19 ± 3 18 ± 4 <0.0001 P<0.001), cerebrovascular involvement (21 vs. 14%; P<0.01) and heart failure Duration of diabetes, years 8 ± 2 8 ± 2 8 ± 2 8 ± 2 0.06 (14 vs. 9%; P<0.01). Using the logistic model, peripheral neuropathy was the complication most strongly associated with cognitive disorders (P<0.001). Females n (%) 409 (58%) 172 (25%) 71 (10%) 49 (7%) <0.0001 Conclusion: These results show a strong association between cognitive POSTERS

Complications Current Smokers n (%) 106 (12%) 23 (10%) 25 (19%) 19 (14%) 0.0002 disorders and peripheral neuropathy. They suggest that screening for Acute and Chronic Systolic BP mm Hg 106 ±11 105±11 108±11 109±12 0.004 cognitive impairment should be performed systematically in elderly type 2 A1c % 8.9 ± 1.7 9.1± 1.8 10.0 ± 2.1 9.6 ± 2.0 <0.0001 diabetic patients. Supported By: Novo Nordisk A/S; Merck Serono Triglycerides mg/dl 82±51 88±50 116±90 115±97 <0.0001 569-P & 567-P Osteoprotegerin Is Associated with Cardiovascular Autonomic Transplantation of Induced Neural Crest Cells from Spheroidal Nerve Function in Type 2 Diabetes Dermal Stem Cells Improves Diabetic Polyneuropathy in Mice RAELENE E. MASER, M. JAMES LENHARD, Newark, DE MASAKI KONDO, HIDEKI KAMIYA, TATSUHITO HIMENO, TETSUJI OKAWA, Osteoprotegerin (OPG), a member of the tumor necrosis factor receptor KEIKO NARUSE, YOJI HAMADA, NAOKO NISHIO, SACHIKO ITO, YUTAKA OISO, superfamily, is a decoy receptor for the receptor activator of nuclear factor KEN-ICHI ISOBE, JIRO NAKAMURA, Nagakute, Japan, Nagoya, Japan KB ligand (RANKL). OPG production has been found in many tissues (e.g., We have identifi ed and established spheroidal dermal stem cells (sDSCs) vasculature) as well as in plasma. OPG is linked to diabetic complications, from skin that possess partial pluripotency, and succeeded to induce neural including peripheral neuropathy (PN) where increased OPG levels may crest cells (NCs) from sDSCs. Here we investigated the effects of NCs represent an abnormal function of the OPG/RANKL signaling pathway in the transplantation on diabetic polyneuropathy (DPN) in mice. development of PN. Cardiovascular autonomic dysfunction results in many We cultured dermal cells from 5-week old EGFP- C57BL/6 male mice and clinical manifestations (e.g., increased risk of mortality) and is caused by a formed 2x10^4 dermal cells into spheroids (sDSCs). NCs were induced from multifactorial process including metabolic, neurovascular, and infl ammatory sDSCs by co-culturing with PA 6 feeder cells for 10 days. NCs (1x10^3 cells components. We hypothesized that OPG levels would be elevated in those per cluster) were transplanted into hind limb skeletal muscles of 12-week with cardiovascular autonomic dysfunction. In this study 50 individuals streptozotocin-diabetic (D) and age-matched normal (N) mice, respectively. (age=63±10 yrs, duration=13±8 yrs, BMI=33±5 kg/m2) with type 2 diabetes, Four-weeks after the transplantation, sciatic motor nerve conduction velocity but no known coronary artery disease, were examined. Parasympathetic (MNCV), sensory nerve conduction velocity (SNCV), sensitivity to thermal nerve function was assessed by RR-variation during deep breathing. RR- stimuli (thermal planter test:TPT), and expressions of NGF, NT-3, VEGF and variation was measured by vector analysis (mean circular resultant (MCR)) bFGF in soleus muscles were assessed. and expiration/inspiration (E/I) ratio. Correlations showed a negative sDSCs expressed several Embryonic stem cell (ESC)-specifi c transcription association between OPG and nerve function (E/I ratio r=-0.37, p=0.015; factors that are the pluripotency markers. Induced NCs expressed Foxd3, MCR r=-0.25, p=0.075 [borderline signifi cance]). Using linear regression Snail and Sox10 that are neural crest cell markers. After transplantation, NCs analysis with MCR or E/I ratio as the dependent variable, the interaction of engrafted in the injected muscles and some showed CD34 or αSMA positive. age x OPG was signifi cant (p<0.01) while controlling for BMI and gender (MCR And we did not fi nd teratoma or other tumors formation. D showed impaired model R2=0.43, p<0.001; E/I model R2=0.70, p<0.001). Our results suggest thermal sensation (TPT; N: 5.5±1.7 s, D: 9.6±3.6) indicating hypoalgesia, and that increased OPG levels are associated with reduced parasympathetic delayed MNCV (N: 53.6±6.9 m/s, D: 36.9±6.7) and SNCV (N: 32.9±4.9 m/s, D: function, with the association being stronger in younger persons than in 21.9±2.7), which were signifi cantly ameliorated by NCs transplantation (TPT: older individuals. It appears that OPG/RANKL signaling abnormalites are 5.2±1.1, MNCV: 48.1±5.5, SNCV: 33.7±5.8). Although there was no change associated with cardiovascular autonomic nerve dysfunction. Mechanisms in the mRNA expression of bFGF, VEGF or NT-3 in NCs-transplanted soleus are unknown but may include microvascular nerve damage, infl ammation muscle, NGF mRNA expression was increased. induced nerve dysfunction as well as a direct role of the autonomic nervous These results indicate that transplantation therapy with induced NCs system. from sDSCs would be safe and effective for DPN, which partially mediated through paracrine actions of NGF secreted by NCs. 570-P Potential Drug-Drug Interactions and Opioid Use among Painful 568-P Diabetic Peripheral Neuropathy Medicare Members Newly Started Cognitive Disorders Are Strongly Associated with Peripheral Neuro- on Pregabalin or Duloxetine pathy in Elderly Type 2 Diabetic Patients of the French GERODIAB LAURA TEN EYCK, ALESIA SADOSKY, JEFFREY J. ELLIS, JOSEPH C. CAPPELLERI, Cohort at Inclusion BRUCE PARSONS, PALLAVI MUDUMBY, LILIAN NDEHI, BRANDON SUEHS, JEAN DOUCET, CHRISTIANE VERNY, BERNARD BAUDUCEAU, THIERRY CONS- Louisville, KY, New York, NY TANS, JEAN-PIERRE LE FLOCH, THE SFD/SFGG GROUP AND THE GERODIAB This study examined the prevalence of potential drug-drug interactions GROUP, Rouen, France, Paris, France, Saint-Mandé, France, Tours, France, Ville- (pDDIs), the impact of pDDIs on healthcare utilization (HCU) and costs, and cresnes, France post-index opioid use among painful diabetic peripheral neuropathy (pDPN) Aim: To evaluate the prevalence of cognitive disorders and associated Medicare members newly started on pregabalin (PGB) or duloxetine (DLX). factors in elderly (70 years old and over) type 2 diabetic patients of the Study members required a PGB or DLX pharmacy claim between 07/01/2008- GERODIAB cohort at inclusion. 06/30/2012 (index event), ≥1 inpatient or ≥2 outpatient medical claims with Patients and Methods: 987 patients with well-preserved autonomy from pDPN diagnosis between 01/01/2008-12/31/2012, and ≥12 months pre- and 56 French diabetic centers were consecutively included in the GERODIAB ≥6 post-index enrollment. Propensity score matching was used to balance follow-up survey to study the 5-year morbidity and mortality. Cognition the PGB and DLX cohorts on pre-index demographics and comorbidities. was systematically explored using the Mini Mental State Examination pDDIs were defi ned by Micromedex 2.0 and identifi ed by prescription claims. (MMSE). Cognitive disorders were defi ned by previously known dementia Six-month post-index HCU and costs were calculated using pharmacy and and/or MMSE score ≤24/30. Results (mean±SD) were analyzed using the medical claims. Continuous and categorical comparisons were conducted t-test or the chi-squared test. Multivariate analysis was a stepwise logistic using Wilcoxon rank-sum tests and chi-square tests, respectively. No regression. signifi cant differences in pre-index demographics or comorbidities were Results: At inclusion, patients with cognitive disorders (n=284; 29%) found between PGB (n=446) and DLX users (n=446). pDDI prevalence was were older than patients without (78±5 vs. 77±5 yr; P<0.001). They were greater (p<0.0001) among DLX users (56.7%) than among PGB users (2.9%). more frequently women (60 vs. 49%; P<0.001), had a lower education level There were no signifi cant differences in HCU or costs between PGB users (P<0.001), similar BMI (30±6 vs. 30±5 kg/m²; NS) and duration of diabetes with and without a pDDI. By contrast, DLX users with a pDDI had higher (18±11 vs. 18±11 yr; NS) but had a higher HbA1c level (62±16 vs. 58±13 mmol/l median all-cause costs ($6,810 vs. $4,841; p=0.001), more users with ≥1 [7.8±1.5 vs. 7.5±1.2%]; P<0.01). In multivariate analysis, cognitive disorders inpatient visits (35.6% vs. 25.4%; p=0.02), and more users with ≥1 emergency were associated with age, gender and HbA1c, successively (concordance room visits (32.8% vs. 20.7%; p=0.005) in comparison to DLX users without a

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A146 COMPLICATIONS—NEUROPATHY pDDI. There was a trend toward a difference between PGB and DLX users in 573-P their respective pre-versus-post differences in milligrams (mg) of morphine Corneal Confocal Microscopy for the Diagnosis of Autonomic equivalents/30 days used (60.2mg and 176.9mg, respectively; p=0.058). The Neuropathy in Diabetic Gastroenteropathy signifi cantly higher prevalence of pDDIs and potential impact on HCU and MITRA TAVAKOLI, PIYARA BEGUM, RAYAZ A. MALIK, JOHN MCLAUGHLIN, costs found in pDPN DLX users, relative to PGB, underscore the importance Manchester, United Kingdom of considering DDIs when selecting a treatment. The diagnosis of Diabetic Gastroenteropathy is diffi cult and most clinicians evaluate cardiac autonomic function tests as a surrogate for

571-P autonomic neuropathy of the GI tract. However, these lack sensitivity and POSTERS Corneal Confocal Microscopy in Children with Type 1 Diabetes: specifi city and can be confounded by concomitant cardiovascular disease Complications Interobserver Agreement and Repeatability of Nerve Fiber Length and cardiac medication and . are also suitable for wider screening of the Acute and Chronic Measurements diabetic population for asymptomatic autonomic disease. We have assessed DANIÈLE PACAUD, KENNETH ROMANCHUK, MITRA TAVAKOLI, CLAIRE the diagnostic utility of the novel technique of corneal confocal microscopy GOUGEON, MYRIAM FERDOUSI, JEAN K. MAH, ALBERTO NETTEL-AGUIRRE, to detect diabetic autonomic neuropathy in patients with DGE. RAYAZ A. MALIK, Calgary, AB, Canada, Manchester, United Kingdom Thirty three subjects with diabetic gastroenteropathy (DGE), 6 Type In children with type 1 diabetes (T1DM), diabetic neuropathy (DN) can 1 diabetic subjects without autonomic symptoms or defi cits (DC) and 18 occur in half of those with a duration of 5 years or longer. Screening for DN by healthy control subjects (C) underwent detailed assessment of neurological nerve conduction studies (NCS) can be time consuming, technically diffi cult assessment, gastrointestinal symptoms Composite Autonomic Symptom and uncomfortable for pediatric patients. Corneal confocal microscopy Scale (COMPASS) and the Composite Autonomic Scoring Scale (CASS) and (CCM) has emerged as a non-invasive surrogate marker of DN in adults, but corneal confocal microscopy (CCM). its repeatability and reproducibility has not been established in children with Corneal nerve fi bre length (3.4 ± 0.6 v 6.9 ± 1.5, P<0.04 v 9.7 ± 0.7, P<0.0001); T1DM. We have assessed the inter-rater agreement per image analyzed and nerve fi bre density (16.8 ± 2.5 v 37.4 ± 4.5, P<0.002, v 48.3 ± 3.3, P<0.0001), per patient (average measure on 4 to 8 images) as well as the reproducibility and nerve branch density (7.7 ± 1.6 v 25.5 ± 2.9, P<0.0001, v 30.1 ± 1.4, of measurements within 1 month. P<0.0001) showed a progressive and signifi cant reduction in DGE v DC v C, Fifty-eight subjects (mean age 14.3 ± 2.4 yrs, range 8 to 18 yrs; 38 with T1D respectively. CCM correlated with COMPASS ( r=- 0.762, P<0.0001) and CASS and 20 controls; 38 males and 20 females) were included. On the initial visit ( r= - 0.762, P<0.0001). Each corneal nerve fi bre parameter demonstrated a (n=58 subjects and 280 images) an average of 6 images per subject were high sensitivty and specifi city for the diagnosis of DGE (CNFD (Sensitivity: manually analyzed by two different independent and blinded observers. One- 85% Specifi city: 82 %), CNFL (Sensitivity: 85%, Specifi city: 64%) and CNBD month repeat visit images were also analyzed by the same blinded observer (Sensitivity: 85%, Specifi city: 88%). in 20 patients. Intraclass correlation coeffi cients (ICC) were calculated and This detailed study demonstrate extremely close relationship between Bland-Altman plots were produced for nerve fi ber length. corneal nerve damage detected using CCM and the severity of autonomic The ICC (95% CI) for single image analysis, average per patient and for neuropathy, providing a rapid, non-invasive, highly sensitive and specifi c the one month repeat were 0.95 (0.93-0.96), 0.88 (0.67-0.92) and 0.81 (0.53- diagnostic test for DGE. 0.92) respectively (all p < 0.01). The Bland-Altman plot indicate a very strong agreement between observers when the same images were analyzed and 574-P a lower, but still acceptable agreement for the overall average nerve fi ber Transplantation of Dental Pulp Stem Cells Improves Sural Nerve length per patient. Morphology in Long-term Diabetic Polyneuropathy CCM image analysis shows good reproducibility with excellent intra- MAIKO OMI KEIKO NARUSE, HITOSHI NUKADA, YASUKO KOBAYASHI, NOBUHISA individual and inter-individual variability in pediatric subjects. Since the NAKAMURA, MASAKI HATA, SHOGO OZAWA, TATSUHITO HIMENO, HIDEKI per image reproducibility is stronger than the per patient reproducibility, KAMIYA, JIRO NAKAMURA, YOSHINOBU TANAKA, TATSUAKI MATSUBARA, refi nement on the method for image selection will likely further increase Nagoya, Japan, Dunedin, New Zealand, Ann Arbor, MI, Nagakute, Japan the robustness of measurements taken through this novel, rapid, and non- The transplantation of stem and progenitor cells ameliorated neuro- invasive approach to detect diabetic neuropathy. physiological disorder in diabetic polyneuropathy. However, it is not clear Supported By: JDRF whether these cell therapies improve nerve morphology and how they affect diabetic polyneuropathy. To address this issue, we have investigated 572-P the morphological changes in sural nerve by dental pulp stem cell (DPSC) The Sole Exercise Can Not Prevent Peripheral Neuropathy in Experi- transplantation in diabetic rats. DPSCs were isolated and cultured from six mental Diabetes week-old male Sprague-Dawley rats. Forty eight weeks after STZ injection, HEUNG YONG JIN, KYUNG AE LEE, TAE SUN PARK, HONG SUN BAEK, SUNHEE DPSCs (1x10^6 cells/rat) or vehicle were injected into the unilateral hindlimb KIM, YUJI KIM, Jeonju, Republic of Korea muscles. Four weeks following the DPSCs transplantation, morphological Exact effectiveness of supportive care such as exercise in diabetes are assessments of sural nerve were performed. To investigate the mechanisms, not clear in the diabetic peripheral neuropathy (DPN) fi eld. Therefore, we mRNA expressions of cultured DPSCs and neurite outgrowth of DRG investigated the effect of regular exercise on the peripheral nerve in the STZ neurons in the presence of DPSC-conditioned media were evaluated. The induced diabetic rats in this study. The animals were divided into six groups decrease in fi ber area, occupancy rate, myelin area, and myelin thickness according to the exercise and glucose control : Normal group, Normal group and the increase in axonal-to-myelin area ratio were found in diabetic with exercise (EXE), diabetic group (DM), DM group with EXE, DM+glucose rat sural nerves. Transplantation of DPSCs signifi cantly ameliorated the control with insulin (INS), and DM+INS+EXE. Animals of exercise were morphological defects of sural nerve in diabetic rats. Cultured DPSCs made to walk on treadmill machine everyday for 30minutes at the 8m/min showed mRNA expressions of bFGF, VEGF, NGF and NT-3. Neurite outgrowth without inclination. After 16 weeks, biochemical, sensory parameters, and of DRG neurons was signifi cantly increased in the presence of DPSC- quantifi cation of peripheral nerves by immunohistochemistry were compared conditioned media. These results suggest that the transplantation of DPSCs among experimental groups. In results, fasting blood glucose levels and may contribute the neuropathological recovery by the secreted neurotrophic HbA1c levels were not infl uenced signifi cantly by exercise in normal and DM and angiogenic factors in long-term diabetic polyneuropathy. groups. However, current perception threshold (CPT) and von frey stimulation test showed higher threshold in the DM+INS+EXE group than DM+INS group 575-P (P<0.05). Signifi cant lower thresholds were observed in untreated DM groups The Association of the 174G>C Polymorphism on Interleukin-6 (DM or DM+EXE) compared with normal and insulin treated DM groups. Gene with Diabetic Neuropathy in Patients with Type 2 Diabetes Intraepidemal nerve fi ber density (IENFD) was less reduced in the DM+INS+EXE Mellitus group than DM+INS group (9.8±0.4 vs. 9.1±0.5, P<0.05), however, exercise STAVROULA PAPAOIKONOMOU, NICHOLAS TENTOLOURIS, DIMITRIS TOUSOUL- did not give a signifi cant benefi t in the respect of IENFD in other groups. IS, DIMITRIS PAPADOGIANNIS, ANTIGONI MILIOU, NIKOLAOS PAPAGEORGIOU, Sole exercise could not show the protective effect on the peripheral nerve GEORGE HATZIS, KONSTANTINOS MAKRILAKIS, CHRISTODOULOS STEFANADIS, signifi cantly in normal and DM group, however, benefi cial effect from exercise Athens, Greece was observed when hyperglycemia was controlled with insulin in DM group. Chronic infl ammatory processes play a key role in the development of These fi ndings suggest that exercise has a protective potential against DPN complications in diabetes. C-reactive protein (CRP) is a marker of systemic based on the fundamental effort for glucose control although sole exercise infl ammation and is associated with micro-and macro-vascular complications cannot prevent peripheral nerve damage from hyperglycemia. of the disease. Whether common polymorphisms of infl ammatory genes

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A147 COMPLICATIONS—NEUROPATHY

are associated with development of diabetic peripheral neuropathy (DPN) by neurological symptoms, neurothe- siometer and electromyography. Firstly, is unknown. The aim of the present study was to examine the association serum cystatin C levels were higher in DPN patients compared with non- of 174G>C polymorphism of interleukin-6 (IL6) gene with DPN in patients DPN patients(1.2(1.0-1.4) vs. 1.1(0.9-1.3)mg/L, p=0.000). Vibration perception with type 2 diabetes mellitus (T2DM). The study population consisted of 431 threshold value and prevalence of DPN increased with the elevation of patients with T2DM (mean age 66.5 ±9.96 years, male n=218, female n=213). cystatin C level. Compared with cystatin C Quartile 1(referent), the risk of The IL6174G>C polymorphism was detected by polymerase chain reaction DPN was signifi cantly higher in Quartile 3(OR, 1.959; 95%CI, 1.007-3.812; and appropriate restriction enzyme digestion (SfaNI). Hs-CRP was assayed p=0.004) and Quartile 4(OR, 2.879; 95%CI, 1.509-5.498; p=0.000). Multiple by particle-enhanced immunonephelometry. Neuropathy was diagnosed regression analysis of DPN showed that age, diabetes duration, smoking, POSTERS

Complications using the neuropathy symptom score and the neuropathy disability score. GA, cystatin C were independent impact factors for DPN. Finally, receiver

Acute and Chronic Prevalence of neuropathy was 36.8%. In the total sample, the genotype operating characteristic (ROC) analysis revealed that the optimal cutoff distribution was GG=49.1%, GC=26.8%, and CC=24.1%, with no signifi cant point of cystatin C to predict DPN in type 2 diabetes patients with normal gender difference. Hs-CRP levels did not differ signifi cantly among the three kidney function was 1.15mg/L(OR=2.467; 95%CI, 1.724-3.530; p=0.000). genotypes. Prevalence (%) of DPN was 47.7 in GG, 29.8 in GC, and 22.5 in CC We concluded that Cystatin C levels are higher in type 2 diabetes patients genotypes (p=0.56). Univariate analysis showed that GG genotype vs. GC or with DPN, and serum cystatin C level higher than 1.15mg/L predict 1.47-fold CC were not associated with increased odds for DPN (p=0.67 and p=0.86, increased risk of diabetic peripheral neuropathy in type 2 diabetes patients. respectively). Similarly, carriers of the ‘G’ allele (GG/GC) were not associated Supported By: NSFC (81270397) with increased odds for DPN in comparison with CC homozygotes (p=0.59). Moreover, carriers of the ‘C’ allele (GC/CC) were also not associated with 578-P increased odds for DPN in comparison with GG homozygotes (p=0.67). The Increased Expression of Cutaneous Mitochondrial Superoxide IL6174G>C polymorphism is not associated with DPN and it does not affect Dismutase in Recently Diagnosed Type 2 Diabetic Subjects serum CRP levels. DAN ZIEGLER, ALEXANDER STROM, JUTTA BRÜGGEMANN, IRIS ZIEGLER, BERND RINGEL, MICHAEL RODEN, GDS GROUP, Düsseldorf, Germany 576-P Oxidative stress resulting from enhanced free-radical formation and Diabetic Neuropathy and Urologic Complications in Men with immune-mediated processes have been implicated in the pathogenesis of Type 1 Diabetes in the Diabetes Control and Complications Trial/ diabetic neuropathy (DN). Since manganese superoxide dismutase 2 (SOD2) Epidemiology of Diabetes Intervention and Complications (DCCT/ is responsible for superoxide detoxifi cation in mitochondria, we hypothesized EDIC) Study that cutaneous SOD2 could be overexpressed in recently diagnosed RODICA POP-BUSUI, BARBARA H. BRAFFETT, PATRICIA A. CLEARY, CATHERINE diabetes. We assessed skin biopsies and peripheral nerve function in a L. MARTIN, JAMES HOTALING, RODNEY L. DUNN, HUNTER WESSELLS, ARUNA subset of 27 participants of the German Diabetes Study (GDS) with recently V. SARMA, DCCT/EDIC RESEARCH GROUP, Ann Arbor, MI, Bethesda, MD, Rockville, diagnosed type 2 diabetes (age: 55.8±6.8 [SD] years; male: 40.7%; diabetes MD, Salt Lake City, UT, Seattle, WA duration: 1.6±1.2 years; HbA1c: 6.8±1.0%) and 17 healthy controls (age: Impaired genital sensory or motor function may promote sexual or urinary 53.8±10.3 years; male: 47.1%). Intraepidermal nerve fi ber density (IENFD) dysfunction, but data in persons with type 1 diabetes (T1D) are limited. We was assessed by immunohistochemistry in 3-mm punch biopsies from the evaluated associations between diabetic peripheral neuropathy (DPN), distal leg. Subepidermal SOD2 area was determined by immunofl uorescence erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) in men using a polyclonal SOD2 antibody. Epidermal Langerhans cell (LC) density with T1D participating in DCCT/EDIC. was quantifi ed using langerin (CD207) staining. Peripheral nerve function DPN was evaluated with a composite of symptoms, neurological was assessed by nerve conduction velocity (NCV) and quantitative sensory examination and nerve conduction studies (NCS) performed at baseline testing. Sural sensory NCV was reduced in the diabetic group vs. control and biennially during DCCT, and at years 13/14 during EDIC. Confi rmed DPN subjects (42.6±6.2 vs. 46.9±4.4 m/s; P<0.001). Subepidermal SOD2 area was defi ned as NCS abnormalities in ≥ 2 nerves and ≥ 2 positive responses was increased by 36% in the diabetic group vs. controls (0.44±0.24 vs. among symptoms, sensory signs, or refl ex changes. ED was assessed using 0.28±0.19%; P<0.05). Epidermal LC density was reduced by 34% in the the question from the International Index of Erectile Function“Over the past diabetic group vs. controls (393±120 vs. 591±152 cells/mm2; P<0.01). IENFD 4 weeks, how would you rate your confi dence that you can get and keep was lower by 24% in diabetic subjects vs. controls (7.5±2.6 vs. 9.9±3.5 fi bers/ erection?” at EDIC year 17. Answers “very low-low” were classifi ed as ED. mm; P<0.02), but this difference was no longer signifi cant after adjusting LUTS was assessed by the American Urological Association Symptom Index for sex, age and BMI. No relationship was noted between SOD2 area and (AUASI). AUASI scores 0-7 were defi ned as no LUTS, and AUASI of 8-35 as LC density or IENFD. In conclusion, cutaneous SOD2 overexpression in the LUTS. lower limbs points to enhanced local oxidative stress independent of LC ED and LUTS data were available from 635 men (mean age 52 years, mean loss in patients with recently diagnosed type 2 diabetes. Whether dermal duration 30 years, mean DCCT/EDIC A1c 7.9%). ED only was reported by 193 SOD2 is an early marker to predict the development of DN remains to be (30%), LUTS only by 61 (10%) and both ED and LUTS by 97 (15%) men. Men determined in prospective studies. with confi rmed DPN at year 13/14 were more likely to report ED (41%), LUTS Supported By: German Federal Ministry of Education and Research (31%) or both ED and LUTS (62%) at EDIC year 17 compared to those without ED or LUTS (22%) (p<0.0001 for all). In multivariable logistic regression 579-P analysis adjusting for DCCT cohort assignment (Intensive vs. Conventional), Prevalence and Clinical Correlates of Diabetic Peripheral Neuro- DCCT/EDIC HbA1c, DCCT/EDIC systolic blood pressure, age, smoking and pathy among Youth with Type 1 Diabetes: SEARCH for Diabetes in drinking status, men with confi rmed DPN had 3.82 (95% CI 2.0-7.3) greater Youth Cohort Study odds of having both ED and LUTS compared to those without DPN. MAMTA JAISWAL, JASMIN DIVERS, SCOTT ISOM, CATHERINE L. MARTIN, Men with T1D and DPN are more likely to report urologic complications ANGELA D. LIESE, LAWRENCE M. DOLAN, DANA DABELEA, DAVID J. PETTITT, than men with no DPN. The temporal relationship between DPN and ED/ CATHERINE PIHOKER, SANTICA M. MARCOVINA, SHARON H. SAYDAH, LUTS in this cohort is under analysis. BARBARA LINDER, RONNY A. BELL, RODICA POP-BUSUI, EVA L. FELDMAN, Ann Supported By: NIDDK Arbor, MI, Winston-Salem, NC, Columbia, SC, Cincinnati, OH, Aurora, CO, Santa Barbara, CA, Seattle, WA, Atlanta, GA, Bethesda, MD 577-P Diabetic peripheral neuropathy (DPN) has not been well defi ned among High Serum Cystatin C Levels Predict Peripheral Neuropathy in children, adolescents and young adults with diabetes. We estimated the Type 2 Diabetes Patients with Normal Kidney Function prevalence of and risk factors for DPN in 1,448 youth with type 1 diabetes FANG LIU, YANYUN HU, HUI ZENG, JING SHEN, WEIPING JIA, Shanghai, China (T1D) and at least 5 years of T1D duration, enrolled in the SEARCH for Recent studies have shown that cystatin C plays a critical role in Diabetes in Youth study, with a baseline and at least one follow up visit. demyelinating and degenerative diseases. We carried out this study to DPN was assessed using the Michigan Neuropathy Screening Instrument explore the relationship between serum cystatin C and diabetic peripheral (MNSI) at the SEARCH cohort visit. MNSI includes a 15-item questionnaire neuropathy (DPN) in type 2 diabetes patients with normal kidney function. and 13-item examination of feet to assess DPN. Research design and methods Totally 795 type 2 diabetic patients were DPN (defi ned as MNSI examination score > 2) prevalence was 6%. In cross randomly enrolled in this cross-sectional study. The demographic and sectional analysis, factors associated with DPN included older age, longer clinical variables were obtained through a questionnaire. Serum cystatin C diabetes duration, smoking, higher BMI, dyslipidemia and higher CRP. A1c was concentration was measured with immunoturbidimetry. DPN was evaluated not associated with DPN in cross-sectional analysis. We assessed glucose

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A148 COMPLICATIONS—NEUROPATHY control over time by A1c area under the curve (AUC), which summarizes the the underlying mechanistic links remain unknown. Insulin plays a critical role trajectory of repeated measurements of A1c over time. AUC for A1c was in regulating muscle microvascular endothelial surface area for nutrient and signifi cantly larger for youth with DPN vs. those without (p< 0.0001). oxygen exchanges. These fi ndings suggest that poor glycemic control over time and To examine whether cerebral microvasculature is also subject to insulin, we cardiovascular risk factors may predict the development of, or predispose fi rst established a contrast-enhanced ultrasound based method to measure young people to DPN. These risk factors are similar to those found in adults cerebral microvascular blood volume (MBV), microvascular fl ow velocity with diabetes. Addressing these modifi able risk factors for DPN in T1D youth (MFV) and microvascular blood fl ow (MBF) in overnight-fasted, anesthetized could reduce DPN prevalence. adult male Sprague-Dawley rats every 30 min for 120 min in the left parietal POSTERS Characteristics of the Youth with Type 1 Diabetes With and Without Dia- cortex, hippocampus and superior colliculus. To assess insulin’s effect, rats Complications betic Peripheral Neuropathy. received a euglycemic hyperinsulinemic clamp (10 mU/kg/min) and cerebral Acute and Chronic MBV, MFV and MBF in the above areas were determined at 0, 10, 30, 60, 90 Variable DPN - DPN + P value N = 1368 (94%) N = 80 (6%) and 120 min. Basal MBV, MFV and MBF remained similar across all time points in all Age (years) 16.9 ± 4.4 20.4 ± 3.7 < 0.0001 three areas. However, superior colliculus had much higher basal MBV (2- Diabetes Duration, years 7.8 ± 1.6 8.7 ± 1.6 < 0.0001 fold), MFV (1.4-fold) and MBF (3-fold) than parietal cortex and hippocampus BMI kg/m2 23.3 ± 4.9 26.3 ± 5.5 < 0.0001 (p<0.001 for all). Insulin infusion promptly increased MBV in parietal cortex LDL-c mg/dl 95.8 ± 27.1 102.6 ± 29.7 0.0255 and hippocampus at 10 min and this effect reached maximum at 30-90 min (by ~60%, p<0.05) without affecting MFV, resulting in a ~70% increase in MBF TG mg/dl 88.4 ± 61.1 106.2 ± 62.4 0.0024 (p<0.05). Insulin did not alter microvascular perfusion in superior colliculus. CRP mg/dl 0.24 ± 0.6 0.53 ± 2.4 0.0054 We conclude that insulin is able to potently recruit microvasculature in HbA1c % 9.1 ± 1.8 9.3 ± 2.0 0.38 parietal cortex and hippocampus which is responsible for spatial sensing and short-term memory respectively, but not in superior colliculus which controls eye movement. Our fi ndings strongly suggest that insulin may play 580-P an active role in the regulation of brain energy metabolism and oxygenation Effects of Exenatide on Measures of Small Fiber Neuropathy in and cerebral microvascular insulin resistance may contribute to cognitive Patients with Type 2 Diabetes decline and memory loss. MAMTA JAISWAL, CATHERINE L. MARTIN, RODICA POP-BUSUI, Ann Arbor, MI Supported By: ADA (1-11-CR-30) Experimental evidence suggests that glucagon-like peptide 1 receptor agonists have neuroprotective and neurotrophic effects independent of 582-P glycemic effects. We explored the effects of exenatide on measures of Changes in Infl ammatory Mediators in DRG of Type 1 Diabetic small fi ber neuropathy, including measures of cardiovascular autonomic Animals with Neuropathy neuropathy (CAN) and intraepidermal nerve fi bers density (IENFD) in adults HAEJEE YOON, VIKRAM THAKUR, MUNMUN CHATTOPADHYAY, Ann Arbor, MI with type 2 diabetes (T2D) and mild diabetic peripheral neuropathy (DPN). Peripheral sensory neuropathy is one of the most common complications of CAN was assessed by deep breathing (E/I ratio) and Valsalva at baseline, 12 diabetes. Accumulating evidence suggests that chronic low-grade infl ammation and 18 months. The IENF regeneration rate 3 and 9 months after capsaicin- involved in the pathogenesis of the disease. We hypothesize that continuous induced denervation was measured in a subset of study subjects. Forty-six release of infl ammatory mediators in the peripheral nervous system causes T2D subjects were randomized to either exenatide (n=22) or glargine (n=24) the sensory neuropathy in diabetic animals; therefore blocking this increase added to their current diabetes therapeutic regimen and followed for 18 will prevent or delay the development of neuropathy. High mobility group box months. At baseline, mean age (54±10years), diabetes duration (8±5years), 1 (HMGB1), a nuclear protein released by injured and severely stressed cells, and A1c (8.2±1.3%) did not differ between groups. No signifi cant changes promotes cytokine release via its interaction with the Toll-like receptor (TLR). were observed for E/I ratio and Valsalva ratio from baseline to 12 months (P = In this study we investigated the changes in cytokine/chemokine profi les in 0.5 and 0.8) or to 18 months (P = 0.8 and 0.1 respectively). Similarly, there the dorsal root ganglia (DRG) and compared the changes in behavior with were no signifi cant differences in the rate of IENFD regeneration at 3 and treatment with TLR4 inhibitor in Type 1 diabetic (T1D) model of pain. At 6 9 months post-denervation between the exenatide- or glargine -treated weeks after hyperglycemia, T1D rats demonstrated signifi cant changes in subjects (P = 0.8 and P= 0.9 respectively)(Figure). thermal hyperalgesia manifested by a decrease in withdrawal latency to heat, These data do not show an effect of 18 months of exenatide treatment on mechanical hyperalgesia measured by the Randall Sellito method of paw measures of small nerve function in subjects with T2D and mild DPN. pressure. T1D rats exhibited marked increases in IL1β and TLR4 at 4 weeks after diabetes as determined by the Western blot analysis and increases in the levels of TNFα, pp38, HMGB1, RAGE by 6 weeks after diabetes. To determine whether increased TLR4 level is responsible for the painful neuropathy in diabetic animals, we injected TLR4 antagonist TAK242 for 3 days at a dose of 1.5 mg/ kg per day I.P. in STZ-diabetic animals, at 4 weeks after diabetes. We tested the pain behaviors in these animals one day before and one day after the injection. The behavior testing shows that animals treated with TAK242 had signifi cant decrease in mechanical hyperalgesia. This preliminary study suggests that TLR4 plays an important role in the infl ammatory aspect of the painful neuropathy in T1D animals. Understanding the mechanisms of diabetic neuropathy may provide a novel treatment approach for this diffi cult-to-treat complication of diabetes. Supported By: ADA (7-12-BS-021)

583-P Corneal Confocal Microscopy (CCM) Detects an Improvement in Small Fibre Neuropathy in Subjects with Type 1 Diabetes Mellitus Supported By: Amylin Pharmaceuticals; AstraZeneca/Bristol-Myers Squibb (T1DM) on Continuous Subcutaneous Insulin Infusion (CSII) SHAZLI AZMI, GEORGIOS PONIRAKIS, MARYAM FERDOUSI, IOANNIS N. PETROPOULOS, UAZMAN ALAM, ANDREW MARSHALL, AHMAD KHEYAMI, 581-P HASSAN FADAVI, MITRA TAVAKOLI, ANDREW J.M. BOULTON, RAYAZ A. MALIK, Insulin Recruits Cerebral Microvasculature in Parietal Cortex and Manchester, United Kingdom Hippocampus but Not Superior Colliculus To establish whether there are any benefi ts of CSII on neuropathy in ZHUO FU, JING WU, AYLOR KEVIN, LINA ZHAO, RICK I. MEIJER, EUGENE J. subjects with T1DM, 50 subjects with T1DM (19 on CSII and 31 on MDI) and BARRETT, ZHENQI LIU, Charlottesville, VA, Amsterdam, Netherlands 40 age matched controls (53.2±2.2 v 48.4±2.5, p=0.88) underwent nerve Insulin acts on the central nervous system to affect appetite, peripheral conduction studies, vibration perception threshold (VPT), cold threshold (CT), metabolism, memory and cognition. Type 2 diabetes and insulin resistance warm threshold (WT) and CCM to assess: corneal nerve fi bre density (CNFD), are established risk factors for the development of Alzheimer’s disease but branch density (CNBD) and fi bre length (CNFL) at baseline and 24 months.

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A149 COMPLICATIONS—NEUROPATHY

At baseline subjects on CSII v MDI had no difference in: duration of addition, WT and db/db mice received introperiponeal injection of dex- diabetes (yrs)(35.2±3.5 v 34.8±3.1, p=0.91), HbA1c mmol/mol (64.2±2.7 v medetomidine (DEX, 50 µg/kg) or BRL44408 (500 µg/kg) or vehicle treatment. 66.7±2.8, p=0.63), BP mmHg (136.5±5.6/74.7+2.3 v 138.5±4.1/71.7±1.2 p= After drug injection, we measured the mechanical threshold and evaluated 0.79), cholesterol mmol/l(4.6±0.3 v 4.1±0.1, p=0.06), HDL mmol/l(1.7±1.3 the ERK activation in the spinal cord. v 1.7±0.1, p=0.83), and triglycerides mmol/l(0.9±0.2 v 1.2±0.2, p=0.49). Results: Our data demonstrated that db/db mice developed transient There was no signifi cant difference for: Peroneal Motor Nerve Conduction mechanical allodynia at the early stage of diabetes. During the period of Velocity (PMNCV) m/s (38.8±2.2 v 40.9±1.1, p=0.66), Peroneal Amplitude mechanical allodynia, we detected increased release of NE and decreased (mV) (3.4±0.52 v 3±0.49, p=0.8), VPT (V) (14.5±2.9 v 16.8±2.6, p=0.51), CT(0C) level of α2A-Adrenoceptor in db/db mice. Immunohistochemistry showed POSTERS

Complications (22.9±2.3 v 25.5±0.95, p=0.77), WT (0C)(40.2±1.2 v 39.6±1.1, p=0.35), CNFD that α2A-Adrenoceptor is predominantly expressed in neurons in the Acute and Chronic (no/mm2) (17.2±1.9 v 20.1±1.6, p=0.34), CNBD (no/mm2) (19.2±2.8 v 23.5±2.7, spinal cord. Acute injection of DEX, a selective α2AAdrenoceptor agonist, p=0.5) and CNFL (mm/mm2) (10.6±1.1 v 12.2±0.8 p=0.4). signifi cantly decreased mechanical allodynia, which can be blocked by its At 24 months the CSII v MDI group showed no difference in: HbA1c mmol/ selective antagonist BRL44408. Furthermore, the upregulation of pERK1 and mol (62.9±2.3 v 66.2±3.0, p=0.86), PMNCV (38.7±2.0 v 40.4±1, p=0.32), pERK2 during the pain hypersensitivity in db/db mice were attenuated by VPT (14.5±10.5 v 16.76±2.1, p=0.18) CT (22.2±2.3 v 23.3±1.4, p= 0.65) or preadminstration of DEX. WT (39.6±1.13 ± 41.3±0.82 p=0.18). The CSII group showed a signifi cant Conclusions: These results suggest that the fuctional alternation of increase in CNBD (25.7±3.52= p=0.03), CNFL (12.3±1.1 p=0.01) and a non- descending noradrenergic system could be an important mechanism for the signifi cant increase in CNFD (19.4±2.4 p=0.09) whilst the MDI cohort showed development of mechanical allodynia in type 2 diabetes. The activatin of α2- a non-signifi cant decrease in CNBD (20.9±2.9), CNFD (18.7±1.8) and CNFL Adrenoceptor represents a potential therapeutic strategy for PDN. (11.9±0.9) with no change in controls; CNFD (29.3±1.9) CNBD (40.3±4.4) CNFL Supported By: NSFC (31371123, 31121061, 31070973) (17.3±0.9). Subjects with T1DM show an improvement in small fi bre neuropathy after 586-P CSII, which can be detected using CCM. Activation of JNK Pathway and Subsequent Infl ammatory Response Supported By: JDRF by Methylglyoxal in Primary Astrocytic Culture KEVIN K. YUE, MAN TAK CHU, Hong Kong, China 584-P Diabetes mellitus (DM) is characterized by chronic hyperglycemia and MIBG Imaging and Left Ventricular Dysfunction Patients with diabetic complications, and it is considered one of the major risk factors in Diabetes Mellitus Type 1 developing neurodegenerative disease such as Alzheimer disease. Astrocyte TRIANTAFYLLOS DIDANGELOS, EFSTRATIOS MORALIDIS, SOFIA MOURATO- regulates neuronal activities in central nervous system, and dysfunction GLOU, THEODOROS KARAMITOS, FOTIOS ILIADIS, ANESTIS ZANTIDIS, ANNA of astrocytes results in abnormal neuronal function and neuronal death. GOTZAMANI-PSARRAKOU, HARALAMPOS KARVOUNIS, APOSTOLOS HATZI- Methylglyoxal (MG) is a reactive metabolite of glucose and an intermediate TOLIOS, Thessa loniki, Greece between glucose and advanced glycation products. In plasma of DM patients To investigate if there is an association between cardiac sympathetic abnormal concentration of MG was observed. MG is known to stimulate activity assessed with 123I metaiodobenzylguanidine (MIBG) imaging and cellular signal transduction and induce infl ammation in various cells. In Left Ventricular Dysfunction (LVD) in patients with Diabetes Mellitus type this study, the deleterious effects of MG on astrocytes were investigated, 1 (DMT1). in which toxicity of MG, and expressions of JNK pathway molecules and Twenty seven patients (13 female), aged 37.6±10 years, with a duration different infl ammatory mediators in astrocytes after MG treatment were of DMT1 20.3±8.9 years, without hypertension and coronary artery disease, determined. receiving only insulin were enrolled prospectively. Participants were evaluated Primary rat astrocytic cultures were prepared and treated with different for autonomic dysfunction with Autonomic Function Tests (AFT) [mean circular concentrations of MG and for different time periods. Cellular viability and resultant (MCR),Valsalva maneuver (Vals), postural index (PI), orthostatic LD 50 were determined by MTT assay, and protein expression of GFAP, JNK hypotension (OH)] and cardiac MIBG [with the ratio of the heart to upper pathway molecules including JNK and c-Jun at different treatment periods mediastinum count density (H/M) at 15 minutes and 4 hours post-injection]. were determined by immunoblotting. mRNA expression of infl ammatory Within one month patients underwent evaluation of systolic and diastolic markers such as TNF-alpha and TGF-beta were determined by RT-PCR. left ventricular function with Tissue Doppler Imaging (TDI). The following With 24 hrs of MG treatment, astrocytic viability was decreased in a indices were measured: Ejection fraction, Sm, E/A ratio, Em/Am and E/Em. dose-dependent manner and LD 50 was observed at around 700 µM. When One patient had two abnormal AFTs, 5 had one and all remaining patients astrocytes were challenged with 700µM of MG for different time periods had normal AFT tests. In contrast, only 3 patients had normal MIBG (30mins, 1hr, 3hrs, 6hrs and 24 hrs), phosphorylation of JNK occurred as measurements (H/M 15min and 4h > 1.80). Indices of MIBG correlated early as 1 hr, followed by phosphorylation of c-Jun at 6 hrs. In addition, up- signifi cantly with the duration of diabetes (H/M 4h: r=-0.470, p=0.02; H/M regulation of TGF-beta, but not TNF-alpha, was observed. 15min: r=-0.439, p=0.03) and indices of diastolic LV function: E/Em (H/M 4h: Our results therefore indicate that MG could induce astrocytic dysfunction r=-0.428, p=0.03; H/M 15min: r=-0.502, p=0.01), Em/Am (H/M 4h: r=0.490; in primary astrocytic cultures via activation of JNK pathway at an early time p=0.01, H/M 15min: r=0.655, p=0.0005). DM duration correlated signifi cantly point, leading to subsequent infl ammatory response such as up-regulation with all AFTs. Indices of systolic function were normal in all patients. of TGF-beta. In DMT1 patients: (a) sympathetic dysfunction, as assessed with cardiac MIBG imaging, is associated with LV diastolic dysfunction, (b) AFTs 587-P (predominantly addressing the parasympathetic system) are insensitive A Prospective Comparative Study of Changes in Small Fibre Function markers of early cardiovascular autonomic neuropathy. Hence, cardiac MIBG in Subjects with Diabetes and Healthy Controls Using the LDIFLARE imaging can predict LV diastolic dysfunction early in the course of DMT1. Technique SANJEEV SHARMA, PRASHANTH R.J. VAS, GERRY RAYMAN, Ipswich, United 585-P Kingdom, Suffolk, United Kingdom Systemic Demedetomidine Reduces Mechanical Allodynia Through Increasing evidence suggests small fi bre dysfunction precedes diabetic ERK Signaling in db/db Type 2 Diabetic Mice polyneuropathy (DPN). The LDI (laser doppler imager) FLARE is a sensitive XU LAN, Wuxi, China method to assess C-fi bre function and may be valuable in identifying those Background: The underlying mechanism of painful diabetic neuropathy at risk of DPN. This prospective study assesses the ability of the LDIFLARE (PDN) is not well understood. Since descending noradrenergic pathway to detect change in small fi bre function (SFF) over 1yr and to determine plays a crucial role in nociceptive modulation, we investigate whether the biomarkers associated with any such change. change of descending noradrenergic pathway mediates the development of 78 T1DM patients (mean age ± SD=41.5yr±15.2), with microangiopathy PDN in db/db mice, an animal model of type 2 diabetes mellitus. (MA+; n=48) and without (MA-; n=30), 82 with T2DM [54.1yr±9.1; MA+ (n=45) Methods: We examined the blood glucose and mechanical threshold in and MA- (n=37)] and 80 healthy controls (HC 47.1yr±15.9) were followed for 1yr. wild type (WT) and db/db mice. During the period of mechanical allodynia All had 3 monthly HbA1c, and baseline and annually, lipids, microalbuminuria, in db/db mice, high pressure liquid chromatography (HPLC), western blot retinal screening, SFF by LDIFLARE, DPN by neuropathy disability scores (NDS), and immunohistochemistry were used to observe the concentrations of and sural nerve amplitude (SNAP) and conduction velocity (SNCV). norepinephrine (NE) and its metabolite 3-methoxy-4-hydroxyphenyglycol At 1yr, LDIFLARE size reduced in T1DM by 6.81±7.07% (mean ± SD), in T2DM (MHPG), the levels and distribution of α2AAdrenoceptor, respectively. In by 5.91±6.52% and only 0.84±0.29% in HC (p< 0.001 each DM group vs. HC).

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A150 COMPLICATIONS—OCULAR

In TIDM, % reduction was signifi cantly greater in MA+ (n=55) vs. MA-(n=23) rats, IMA improves diabetes-related bladder dysfunction involving in partial (8.7±1.2 vs. 4.6±1.1%; p<0.0001) whereas in T2DM there was no signifi cant reversal effect on high glucose levels and restoration of PDGF-β activation difference in MA+ (n=49) vs. MA-(n=33) (4.92±1.46 vs. 6.02±0.77%; p=0.06). which may progress diabetic cystopathy. Hence, PTKs may be a viable target In both T1 and T2 DM,% change in SFF correlated with change from for bladder dysfunction of diabetic patients. baseline HbA1c (p<0.0001for both) and triglyceride (TG) (p<0.0001; p=0.03 respectively). In HC the % change in SFF also correlated with TG change 590-P (p=0.008). In no group did change in SFF correlate with BMI, other lipid Hyperbaric Oxygen Therapy Seems to Protect Against Qtc Impair- indices or blood pressure (BP). NDS, SNAP and SNCV did not signifi cantly ment in Patients with Diabetes and Hard-to-Heal Foot Ulcers POSTERS change in any group, nor correlate with changes in HbA1c, lipids or BP. KATARINA FAGHER, PER KATZMAN, MAGNUS LÖNDAHL, Lund, Sweden Complications We conclude that in HC, T1 and T2 DM, changes in TGs correlate with Heart rate corrected QT (QTc) interval prolongation is a risk factor Acute and Chronic change in LDIFLARE. Furthermore, the additional correlation with change in associated with increased mortality in non-diabetic as well as diabetic HbA1c in the diabetic groups probably explains their signifi cantly greater patients. Several factors, i.e. hereditary disorders, coronary heart disease, change in SFF compared with HC. Long term studies are required to cardiac autonomic neuropathy and microvascular disease, may all contribute determine whether such changes are predictive of later DPN. to QTc prolongation. Hyperbaric oxygen therapy (HBO) may enhance microvascular function 588-P and has been shown to have acute benefi cial effects on QTc dispersion. Maximizing the Accuracy of Nerve Conduction Velocity Measure- The aim of this study was to evaluate long-term effects of HBO on QTc ments in an Effi cacy and Safety Study of Long-Acting C-Peptide time in diabetic patients with hard-to-heal foot ulcers. (Ersatta[TM]) in Type 1 Diabetes Patients (ACT1VE) In a prospective randomized double-blinded placebo-controlled study (the MARK DANIELS, JOSEPH AREZZO, SHIRLEY SETO, JOHN WAHREN, DENNIS HODFU study, design presented elsewhere) effects of HBO was evaluated in KIM, HOWARD FOYT, JOEL MARTIN, San Diego, CA, Bronx, NY this population. Patients were randomized to 40 (90 minutes long) treatment Nerve conduction velocity (NCV) provides a sensitive, objective and sessions with either oxygen or air, at 2.5 ATA in a hyperbaric chamber. targeted measure of both effi cacy and safety in clinical trials of peripheral Patients fulfi lling (per-protocol requirement) at least 36 completed treatment neuropathy. The FDA has accepted this measure as a clinically relevant bio- sessions were included in the evaluation. Non-parametric statistics were marker. used and a two-sided p<0.05 was considered as statistical signifi cant. In diabetes, the distal sural sensory nerve is vulnerable to axonopathy. Of the initial 75 patients (38 HBO / 37 placebo), one in each group was Assessment of NCV in this nerve segment is often associated with excluded due to pacemaker use. Baseline characteristics were similar considerable variability, especially in large multicenter studies involving between groups. At the 2-year follow-up, QTc time was signifi cantly lower in multiple countries. In the ongoing Assessment of C-peptide in Type 1 the HBO group as compared to the placebo group (438 vs. 453 ms, p<0.05). Diabetes Mellitus on NCV Evaluation (ACT1VE) study, 250 patients have been Further, fewer HBO treated patients had a QTc time above 450 ms after 2 enrolled. Key eligibility criteria include: having stable type 1 diabetes for 5 years (22 vs. 53 %, p<0.02). This difference seems to be related to a QTc years and recordable sural sensory nerve responses consistent with mild to prolongation in the placebo group, as QTc time was similar at 0, 1 and 2 years moderate diabetic peripheral neuropathy (at least two standard deviations in the HBO group; 426, 435 and 438 ms respectively, whereas a signifi cant [SD] below the age-corrected mean). Patient baseline characteristics: age prolongation was seen in the placebo group; 427, 434 and 453 ms (p<0.05). 46.7±12.4 years, HbA1c 7.8±1.3%, duration of diabetes 27.2±13.7 years, sural Accordingly, as indicated in our evaluation, HBO treatment might protect NCV 41.2±3.7 m/sec. against QTc interval impairment in this high mortality risk diabetic population. NCV variability has been substantially improved by combining best Supported By: Lund University practices including standardization of technique, strict limb temperature control, review of the recorded waveforms by a central laboratory, bilateral assessment, duplicate measures and the addition of a third measure in COMPLICATIONS—OCULAR instances of >12% variability in NCV from the same nerve on the same side. The application of these procedures has resulted in the repeat measure SD for the sural nerve of ~1.3 m/sec corresponding to a coeffi cient of variation Guided Audio Tour: Putting the Function Back into the Dysfunctional of 3.2% for all patients (535 NCV assessments). The reliability achieved Retina (Posters: 591-P to 598-P), see page 13. using the outlined procedures will improve the reproducibility and therefore the statistical power of this key measure to detect possible therapy-induced & 591-P changes over the study period. Ranibizumab for Diabetic Macular Edema: Long-term Open-Label Extension of the Phase III Ride and Rise Trials 589-P ANNE FUNG, ARTHUR FU, JIAMENG ZHANG, JASON S. EHRLICH, San Francisco, Imatinib Mesylate (Gleevec, a Protein Tyrosine Kinase Inhibitor) CA, South San Francisco, CA Improves Urinary Bladder Dysfunction in Diabetic Rats Diabetic retinopathy (DR) is the most common complication of diabetes, SERAP GUR, Ankara, Turkey and is a leading cause of blindness. RISE and RIDE were prospective, Diabetes mellitus causes diabetic bladder dysfunction. The protein tyrosine 3-year Phase III trials in patients with diabetic macula edema (DME) kinase (PTK) inhibitor, imatinib (IMA, GleevecTM, Novartis Pharmaceuticals, that demonstrated improvement of best corrected visual acuity (BCVA), Basel, Switzerland) has therapeutic potential in diabetes by maintaining reduction of the excess fl uid in the retina and inhibition of DR worsening, on β-cell function. We determined if IMA has a benefi cial effect on bladder average, with monthly ranibizumab (RBZ), a monoclonal antibody fragment function in streptozotocin (STZ)-induced diabetic rats. Male Sprague- specifi cally designed for intravitreal eye injection to inhibit vascular Dawley rats were divided into four groups: 1) Control, 2) IMA-treated control endothelial growth factor-A (VEGF). Patients completing RISE and RIDE (50mg/kg, daily gavage), 3) STZ-diabetic (40mg/kg, iv) 4) IMA-treated were eligible to participate in a long-term, open-label extension study to diabetic rats. Rat bladder strips were suspended in organ baths for isometric evaluate the effi cacy and safety of less-than-monthly RBZ as maintenance tension recording. Platelet-derived growth factor (PDGF)-β tyrosine kinase therapy. Patients received RBZ only if experiencing a signifi cant decrease in was evaluated by immunohistochemistry with a semiquantitative analysis. BCVA from Month 36, or if recurrence of DME was detected using optical Diabetic rats at 8 weeks demonstrated lower body weight, higher blood coherence tomography imaging. glucose and mean voided volume, as well as less voiding frequency than BCVA gains and resolution of edema achieved after completion of the control rats. IMA-treated diabetic rats gained weight, partially reversed monthly treatment phase were maintained using less-than-monthly dosing blood glucose levels and bladder parameters. Contractile responses of in the extension. An average of 4.5 injections were administered over a bladder strips from diabetic group were signifi cantly enhanced for carbachol mean 14.1 months follow-up, with <10% of patients continuing monthly RBZ. and adenosine triphosphate, which were improved by IMA treatment. There ~25% of previously treated patients did not require RBZ treatment during the was no change for contractile responses related to EFS in groups. However, extension. By the end of extension, patients with RBZ treatment deferred by the EFS-induced contractile responses of diabetic bladders with incubations 2 years (randomized initially to sham) still did not achieve the same VA gains of PPADS (nonselective P2 antagonist) and atropine (cholinergic antagonist) as those who received RBZ from baseline. Adverse events were consistent were signifi cantly lower than in control bladders, which were returned by with the known safety profi le of ranibizumab. IMA treatment. PDGF-β staining was more intensive in diabetic samples, These data demonstrate that less-than-monthly treatment can be which was obserbed in normal abundance in treated samples. In diabetic suffi cient to maintain improvements in vision for the majority of patients

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with DME after initial, more intensive treatment. Providers should be aware of the effi cacy of therapies for DME, and inform their patients of & 594-P the importance of regular eye examinations by a qualifi ed ophthalmologist Inherited Mitochondrial Dysfunction Exacerbates Diabetic Compli- to ensure that retinal complications of diabetes are identifi ed and treated cations promptly for maximal vision outcomes. RACHEL BLAKE, VICKI CHRYSOSTOMOU, ANDRZEJ S. JANUSZEWSKI, BEN MA, YUAN ZHANG, DARREN KELLY, ALICIA J. JENKINS, JONATHAN CROWSTON, & 592-P IAN TROUNCE, Melbourne, Australia, Fitzroy, Australia Even with insulin treatment, long-term mild hyperglycaemia leads to retinal,

POSTERS Dynamic Changes in Retinal Vessel Diameter During Hyperglycemia

Complications renal and cardiovascular disease. Studies have shown altered mitochondrial BRIAN C. BUCCA, DAVID M. MAAHS, JANET K. SNELL-BERGEON, JOHN E. Acute and Chronic function in the presence of hyperglycaemia, but the consequence of inherited HOKANSON, FRANZISKA BISHOP, ALEXIS BOUFARD, SEAN P. RINELLA, JOANNA mitochondrial dysfunction on diabetic complications has not been addressed. HOMANN, CAROL Y.L. CHEUNG, TIEN-YIN WONG, Aurora, CO, Singapore, Singa- We hypothesize that mitochondrial dysfunction exacerbates complications pore associated with type 1 diabetes. We used a xenomitochondrial mouse with Retinal vessel diameter has been suggested to be a preclinical marker evolutionarily divergent nuclear and mitochondrial DNA, resulting in a mild of diabetic complications including retinopathy and nephropathy. The short- impairment of oxidative phosphorylation. term infl uence of dynamic variables such as blood glucose on measures of Beta cell loss was induced with streptozotocin and hyperglycaemia was retinal vessel width is not known. Our objective was to investigate changes maintained for 20 weeks. To mimic patient treatment regimes, an additional in retinal diameter during hyperglycemia. cohort was also treated with insulin. Euglycemia (72-108 mg/dl) was maintained for 3 hours in 11 fasting, In the retina, we demonstrate a 30% decrease in pSTR in diabetic normotensive and normoalbuminuric subjects with type 1 diabetes (T1D) xenomitochondrial mice compared to diabetic wild type mice, suggesting (T1D duration 22+10y, age 32.4+14y). Breakfast with simultaneous rapid functional impairment in the inner retina. We were also able to demonstrate acting insulin induced hyperglycemia (fasting=93.6±15.4 mg/dl, 2 hour increased metabolic by-products of hyperglycaemia, and increased heart post-prandial=218±45 mg/dl). After resting for 5 minutes, two 45° mydriatic and kidney fi brosis in xenomitochondrial diabetic mice. In diabetic animals fundus photos of fi eld 1 were captured spaced by 1 hour during euglycemia. we also found increased evidence for oxidative damage and mitochondrial- Five additional fundus photos were taken starting 30 minutes post-meal linked ROS production. and every 30 minutes for 2.5 hours. Blood glucose and blood pressure We have been able to show that inherited mitochondrial dysfunction were recorded at each photo time point and subjects remained minimally exacerbates pathology associated with prolonged hyperglycaemia, which ambulatory and in a consistently illuminated room. Central retinal artery adds to evidence of mitochondrial involvement in complication development. equivalent (CRAE) and central retinal vein equivalent (CRVE) were measured in zones B and C using Singapore 1 Vessel Analysis (SIVA). Changes in CRVE and CRAE in zones B and C over the study visit were examined in generalized linear mixed models using the SAS 9.3. In a multivariate mixed model adjusted for age, sex, T1D duration, retinopathy presence, A1C and insulin infused to achieve euglycemia, mean change in CRAE and CRVE in zone B were -2.13um (p=0.006), -2.47um (p=0.06) respectively and -1.99um (p=0.07), -4.0um (p=0.001) in zone C at 90 minutes post-prandial. Further, systolic and diastolic blood pressure decreased signifi cantly by 150 minutes post-prandial (-7.2 mm Hg, p=0.002 and -7.4 mm Hg, p=0.02, respectively). These results suggest that retinal blood vessel diameter and blood pressure varies during hyperglycemia in persons with T1D. The role of hyperglycemia should be considered when measuring and interpreting investigations of retinal vessel diameter.

& 593-P Synergistic Effect of Hyperglycemia and Adenosine Upregulation in Diabetic Retina on Microvascular Dysfunction REHAE C. MILLER, SERGIO LI CALZI, MARIA B. GRANT, Indianapolis, IN The microvascular dysfunction observed in diabetic retina is caused in part by elevated plasma glucose levels. The levels of the purine nucleoside, adenosine, are also elevated in diabetic retina1. The purpose of this study was to determine whether elevated glucose and adenosine can act & synergistically in diabetic retinal microvasculature. To test this hypothesis, 595-P Imaging of Hypoxia in the Mouse Retina we examined the effects of high glucose and adenosine on expression of ASHWATH JAYAGOPAL, STEPHANIE EVANS, Nashville, TN hypoxia induced factor-1α (HIF-1α) and vascular endothelial growth factor The initiation and progression of diabetic retinopathy has been associated (VEGF) in human retinal endothelial cells (HREC). We also explored whether with retinal hypoxia. Therefore, technologies for imaging hypoxic retinal the glucose response element, carbohydrate response element binding tissue in vivo may be useful for improving clinical management of this protein (ChREBP), is involved in HIF-1α expression in HREC. disease. For this purpose, a hypoxia-sensitive fl uorescent contrast agent Exposure of HREC to the adenosine analog, 5’-N-ethylcarboxamidoadenosine was developed and characterized for imaging of hypoxia in retinal tissue NECA, increased nuclear HIF-1α protein, while high glucose (HG) exposure using established cell culture and animal models of retinal vascular disease. (25 mmol/L) induced the expression of VEGF protein. This increase of Fluorescently-labeled, hypoxia-sensitive contrast agents were synthesized, VEGF was attenuated by an adenosine receptor 2B (ADOR2B) antagonist purifi ed chromatographically, and characterized by mass spectrometric and (MRS1754). Immunocytochemistry demonstrated that ChREBP is expressed nuclear magnetic resonance analyses. In vitro assays using Human Retinal in HREC and that high glucose induces its nuclear translocation. The nuclear Microvascular Endothelial Cells (HRMEC) and in vivo studies using mice with translocation of ChREBP was signifi cantly greater in cells treated with both oxygen-induced retinopathy (OIR)to model features of proliferative diabetic HG and NECA and resulted in increased nuclear HIF-1α . In summary, our retinopathy were performed to determine the hypoxia-associated sensitivity studies suggest that high glucose and NECA synergistically upregulate and specifi city of this contrast agent. HRMEC conditioned under hypoxia for nuclear HIF-1α protein expression. ChREBP by translocating to the nucleus var ying durations of time up to 24 hrs. exhibited dose-dependent fl uorescence following high glucose exposure can facilitate HIF expression and increased enhancement due to hypoxia-selective uptake of the contrast agent. In OIR VEGF contributing to the pathogenesis of diabetic retinopathy. animal models, regions of tissue hypoxia staining positive for pimonidazole 1. Vindeirinho, J., G. N. Costa, M.B. Correla, C. Cavaas, P. F. Santos (2013) hydrochloride were also colocalized with contrast agent uptake, as indicated Effect of diabetes/Hyperglycemia on the Rat Retinal Adenosinergic System. by in vivo and ex vivo imaging. Contrast agent accumulation in hypoxic PLOS One 8(6): e67499-67499. tissue was detectable within 2 hrs. post-injection. These studies support the feasibility of imaging hypoxic tissue in vivo using targeted contrast agents in conjunction with readily available retinal fl uorescence imaging equipment.

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Hypoxia-sensitive contrast agents, if clinically translated, may be useful for early detection of diabetic retinopathy, as well as monitoring of therapeutic & 598-P response in patients. Mechanism of Cone Maintenance in Diabetic Retinopathy Supported By: ADA (7-12-JF-30); R01EY023397; BrightFocus Foundation YUN-ZHENG LE, Oklahoma City, OK Alteration and death of photoreceptors are pathological characteristics & 596-P in diabetic humans and animals. To investigate the mechanisms governing diabetes-induced photoreceptor degeneration, we utilized a mouse model Bone Marrow (BM) Microenvironment in Type 2 Diabetes (T2D): that had been shown to have impaired stress-induced survival in rod

Impact on Hematopoietic Progenitor Cell (HPC) Function POSTERS

photoreceptors. To our surprise, this mouse model also demonstrated Complications TATIANA SALAZAR, Gainesville, FL accelerated cone photoreceptor loss in diabetes. To determine the Acute and Chronic The BM niche is home and birthplace to HPC. HPC are crucial for vascular mechanisms of cone maintenance in diabetes, we characterized this health, tissue repair, and adequate immune response. In T2D, the BM animal model and examine the gene expression profi le in diabetic animals. undergoes a series of changes with disease progression and transitions Rod-specifi c Bcl-x knockout (KO) mice were used in our study. Diabetes from a hematopoietic-rich environment to increased adiposity and elevated was induced with streptozotocin (STZ). Retinal function was measured levels of TNF-α and adiponectin. These changes impact hematopoiesis and with electroretinography (ERG) and retinal morphology was assessed HPC function, leading to diabetic complications. In this study, we used the with hematoxylin & eosin (H&E) stained sections. Cone density was T2D model Leprdb (db/db) to characterize the changes in the diabetic BM evaluated with immunohistochemistry. Gene expression was analyzed microenvironment with the progression of diabetes (D) and its effect on HPC. with immunoblotting. Eight months after STZ injection, rod-specifi c Bcl-x The non-obese, non-D form of the strain (db/m) was used as a control. KO mice demonstrated accelerated loss of outer nuclear layer (ONL) Mice were euthanized at 2, 6 and 9 months of D. While there were no thickness and rod photoreceptor function, compared with that of wildtype differences in HPC percentage in peripheral blood, db/db mice showed animals. Interestingly, cone photoreceptor function, as measured by increased HPC in the BM at all time points (p<0.05). When cultured in colony- photopic ERG, was signifi cantly reduced, compared with wildtype controls. forming cell assays, cells from the early and mid-stage D (2 and 6 months) Immunohistochemical analysis of S-opsin and M-opsin, markers for cone showed increased granulocyte/macrophage colony formation compared to photoreceptors, showed that cone density was also signifi cantly reduced in db/m, (CFU-GM and CFU-GEMM, p<0.001). However, advanced D (9 months), diabetic rod-specifi c Bcl-x KO mice, compared with wildtype animals. Among showed decreased colony formation compared to db/m (p<0.001). HPC a panel of proteins examined, the conditional Bcl-x KO mice demonstrated proliferation was measured through the use of a BRdU ELISA, and found to marked reduction in activated AKT and rod-derived cone viability factor-2 be elevated early in D, but diminished with the progression of the disease (RDCVF2) in retinal extracts. Our data show that BCL-xL, a PI3K-AKT survival (p<0.01). Cytokines were measured in the BM supernatant using bead protein pathway downstream target, is involved in rod photoreceptor protection in arrays. In early D, M-CSF concentrations were elevated in the BM (p=0.02), DR. Our results suggest that rod integrity is essential to the maintenance of but later became lower than the db/m (p=0.012). At 6 months, db/db showed cone in DR through RDCVF2. reduced IL-10 and VEGF when compared to the db/m (p<0.001 and p=0.02, Supported By: NIH (GM104934, EY020900) respectively). Diabetic retinopathy (DR) was used as a representation of development of D vascular complications. As expected, db/db mice had elevated acellular capillaries compared to db/m (p=0.02). Our study suggests 599-P that the early rise in BM HPC proliferation could be a compensatory effect Glucose-induced Endothelial-to-Mesenchymal Transition (EndMT) to the widespread vascular damage present in D but as disease progresses in Diabetic Retinopathy compensation is lost and HPC function decreases promoting DR. YANAN CAO, BIAO FENG, SHALI CHEN, YANHUI CHU, SUBRATA CHAKRABARTI, Supported By: NIH (2R01EY012601) Mudanjiang, China, London, ON, Canada Hyperglycemia induced endothelial cell (EC) dysfunction is important in & 597-P the pathogenesis of diabetic retinopathy. Chronic injury changes phenotype of ECs, leading to reduced expression of EC specifi c transcripts and Long Non-Coding RNA Anril Regulates Glucose-induced VEGF overexpression of mesenchymal transcripts, a process named endothelial- Expression in the Retina through miR-200b to-mesenchymal transition (EndMT). Here, we investigated if glucose causes BIAO FENG, YANAN CAO, SHALI CHEN, XURAN CHU, SUBRATA CHAKRABARTI, EndMT in the human retinal ECs (HRECs) and in the retina of diabetic animals London, ON, Canada, Mudanjiang, China and the mechanisms of such changes. Long-non-coding RNAs (lncRNAs) are possiblly involved in the regulation HRECs were exposed to 5mM (NG) and 25mM glucose (HG), NG with of various cellular functions. One of the lncRNA, Anril has already been TGF- 1 and HG with TGF- 1 blocker. mRNA levels of EC markers [CD31 shown to play a pathogenetic role in atherosclerosis and in various cancers. β β and VE-cadherin (VE-cad)], mesenchymal markers [fi bronectin (FN), SM22, However, role of lncRNAs in chronic diabetic complications is unknown. We collagen 1(I and IV) (COL4a1 and COL1a1) and vimentin (VIM)], miR-200b have previously shown that microRNA 200b (miR-200b) regulates glucose- α and TGF- 1 related factors [Smad2 and Snail1] were quantifi ed by real- induced VEGF production in diabetes. Here we examined whether Anril is β time quantitative RT-PCR. Western blot or ELISA were used to detect altered in diabetes and whether such alteration is of signifi cance in such protein levels. Endothelial and mesenchymal markers were examined using pathway. immunofl uorescence. In vivo experiments in retinal tissues were performed We examined human retinal endothelial cells (HRECs) treated with low (5mM) in EC specifi c miR-200b overexpressing transgenic mice (generated in our and high (25mM) glucose levels. They were examined for miR-200b, Anril and laboratory) and in wild type controls, with or without STZ induced diabetes. VEGF levels by real time RT-PCR. Furthermore, HRECs, transfected with Anril Subsequent to HG exposure or TGF- 1 incubation of HRECs, decreased siRNA, were examined similarly. We further examined E2F1 transcription factor, β expression of EC markers (CD31 and VE-cad), and increased expression a regulator of Anril. In vivo experiments were carried out in endothelial specifi c of mesenchymal markers (FN, SM22, COL4a1 and COL1a1, and VIM) were miR-200b overexpressing transgenic mice (generated in our laboratory) and in seen, compared to NG. Such changes were corrected by TGF- 1 blocker. In wild type controls, with or without STZ induced diabetes. β parallel, HG caused reduced miR-200b with over-expression of two miR-200b In the HRECs, high glucose increased Anril, E2F1 and VEGF expression target genes, Smad2 and Snail1. Similarly, in retina of wild type mice with and decreased miR-200b production. Anril siRNA transfection signifi cantly diabetes, decreased expression of EC markers, and increased expression of increased miR-200b expression and reduced decreased VEGF expression mesenchymal markers were seen compared to control. Such changes were in the high glucose treated HRECs. Anril siRNA also decreased HRECs prevented, in the diabetic miR-200b transgenic mice. proliferation . Furthermore, glucose induced VEGF mRNA upregulation, but These studies showed occurrence of EndMT in diabetic retinopathy, not Anril upregulation in the HRECs were suppressed by miR-200b mimics which is mediated through TGF- 1 and miR-200b. Identifi cation of such transfection. In retina of wild type mice with diabetes, VEGF, Anril,and β mechanisms may lead to the development of novel therapeutic strategies. E2F1 were increased compared to control, the former was prevented in the Supported By: CDA diabetic miR-200b transgenic mice. These results indicated that long-noncoding RNA Anril may regulate glucose induced increased VEGF production through miR-200b. Furthermore Anril may be regulated by transcription factor E2F1. Understanding the roles of lncRNAs in diabetes may potentially open up novel therapeutic targets in diabetic retinopathy. Supported By: CDA

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600-P 602-P A Cross-Sectional Multiethnic Study of Diabetic Retinopathy: A Does HbA1c Level Infl uence the Effi cacy of Ranibizumab for Improv- Useful Method of Assessing Quality of Diabetes Care ing Vision in Patients with Diabetic Macular Edema? MARIA I. CONSTANTINO, LYNDA MOLYNEAUX, TURKI ALHARBI, TED WU, ALOK S. BANSAL, RAHUL N. KHURANA, MARK R. WIELAND, PIN-WEN WANG, JENCIA WONG, DENNIS K. YUE, Camperdown, Australia, Sydney, Australia SHERRI A. VAN EVEREN, LISA TUOMI, Mountain View, CA, South San Francisco, CA We examined in 7 ethnic groups with T2DM over two periods (i) the rate Ranibizumab (RBZ) is a monoclonal antibody fragment targeted against of diabetic retinopathy(DR) development (a measure of glycaemic exposure) vascular endothelial growth factor (VEGF), a protein known to be upregulated

POSTERS and (ii) presence of DR at diabetes diagnosis (a measure of delay in diabetes in patients with diabetic macular edema (DME). RBZ is FDA approved for

Complications diagnosis). the treatment of DME based on two similarly designed Phase III, clinical Acute and Chronic Using our database, the relationship between DR prevalence and known trials (RISE and RIDE, n=759), in which patients with DME were randomized diabetes duration was examined by weighted linear regression for Anglo- to either monthly intravitreal RBZ or sham injection (control, needle-less Celtic (3684), Mediterranean (2342), Arabic (511), Chinese (1180), Indian syringe). In patients treated with monthly 0.3 mg RBZ for 24 months, best- (500), Australian Aborigines (350) and Pacifi c Islander (249) patients. The correct visual acuity (BCVA) improved by +11.7 ETDRS letters compared to slope of the regression is an index of DR development. By extrapolation, only +2.5 ETDRS letters in the sham group. Although RBZ provides robust the presence of DR at the time of diabetes diagnosis (y intercept) and the improvements in vision in patients with DME, the effect of HbA1c on response delay in diabetes diagnosis (x intercept) were estimated. DR was detected to treatment for DME has yielded inconclusive results. The purpose of this by ophthalmoscopy or photography. study is to investigate the relationship between HbA1c and improvement in The ethnic groups showed different and declining rates of developing BCVA associated with RBZ therapy. DR, except the Aborigines and Pacifi c Islanders, consistent with the higher For the present study, we conducted a post-hoc analysis of RIDE and and less improvement of HbA1c in these two ethnic groups. Aboriginies RISE, whereby improvements in BCVA were assessed according to baseline also showed no reduction in the delay of diabetes diagnosis. The pattern of HbA1c cutoffs: ≤7% vs. >7%, and ≤8% vs. >8% through month 24. The ethnic differences in DR development was also observed for severe DR but mean baseline HbA1c for the study population was 7.7% and remained no delay in diabetes diagnosis was evident. stable throughout the study, with a slight increase of 0.17% at Month 24. In patients treated with monthly 0.3 mg RBZ for 24 months, BCVA improved +11.9 ETDRS letters in patients with baseline HbA1c >7%, compared with +11.8 letters in patients with baseline HbA1c ≤7%. Similar results were seen using an HbA1c comparison threshold of 8%. Thus, no clinically meaningful association was observed between baseline HbA1c and BCVA improvement achieved with RBZ. These results support the effi cacy of RBZ for the improvement in visual acuity in DME regardless of HbA1c status in the RISE/RIDE study population. We conclude that the study of DR prevalence at different diabetes durations is useful in assessing the quality of diabetes care in populations. 603-P The relationship between glucose level with varying severity of DR may be Dipeptidyl Peptidase-4, a Novel Adipokine, Enhances Superoxide different. Production in Porcine Retinal Arterioles SHINJI ONO, TAIJI NAGAOKA, TSUNEAKI OMAE, TAKAYUKI KAMIYA, SHINICHI 601-P OTANI, AKITOSHI YOSHIDA, Asahikawa, Japan Type 1 Diabetes and Fracture Risk: A Population-based Study Using Purpose: Dipeptidyl peptidase-4 (DPP-4) is a protein with a major role in The Health Improvement Network (THIN) degradation of incretin peptide hormones, which lower glucose. Recently, DAVID R. WEBER, KEVIN HAYNES, MARY B. LEONARD, STEVEN M. WILLI, DPP-4 was identifi ed as a novel adipokine released from adipose tissue. MICHELLE R. DENBURG, Philadelphia, PA Epidemiologic studies have confi rmed that elevated serum DPP-4 levels are There is increasing evidence that type 1 diabetes (T1D) negatively impacts associated with type 2 diabetes, suggesting that DPP-4 overproduction may skeletal health. The onset of T1D is highest in childhood; however previous be involved in the pathogenesis of diabetic microvascular complications studies have focused primarily on hip fracture (FX) in adults. We performed a including retinopathy. However, the direct effect of DPP-4 on retinal retrospective cohort study using THIN, a UK primary care electronic medical microvasculature is unknown. We investigated whether DPP-4 affects records database, to determine if T1D was associated with FX risk across endothelium-dependent nitric oxide (NO)-mediated dilation of retinal the lifespan. We compared 30,394 subjects with T1D to 303,872 randomly arterioles and if oxidative stress is involved in that effect. selected non-diabetes (DM) subjects matched by age, sex, and practice. Methods: Porcine retinal arterioles were isolated, cannulated, and Hazard ratio (HR) for fi rst FX was estimated by Cox regression analysis. pressurized without fl ow in vitro. Diameter changes were recorded using a Median age was 35y (IQR: 25-50); 45% were female. With median follow-up videomicroscopic technique. To evaluate the vessel endothelial function, the of 4.7y (IQR: 2-9), 2615 fi rst FX events occurred in T1D (174/10,000 person- reactivity to the endothelium-dependent NO-mediated agonist bradykinin yrs) vs. 18,624 in non-DM (107/10,000 person-yrs). There was increased FX (10 nM) was used. We compared the endothelial function before and 180 risk for T1D across the lifespan (Figure). The effect of T1D on FX risk varied minutes after intraluminal incubation with DPP-4 (1,000 ng/ml). by sex and also by age in males (p for interactions <0.01). Distribution of FX Results: Intraluminal DPP-4 treatment signifi cantly (P=0.0019) attenuated site varied in T1D vs. non-DM (p<0.001); especially notable was a HR of 6.6 bradykinin-induced vasodilation from 82.3±3.6% (mean ± standard error (3.4,12.8) in females and 4.9 (2.6,9.1) in males for hip/femur FX among 50-59y of the mean) to 37.2±8.6%. In contrast, reactivity to the endothelium- T1D subjects. The lifelong burden of FX risk in T1D and the disproportionate independent NO donor sodium nitroprusside was unaltered. In the presence contribution of hip/femur FX to overall T1D FX risk have important public of the superoxide scavenger TEMPOL, the detrimental effect of DPP-4 on health implications. bradykinin-induced vasodilation decreased signifi cantly. Conclusions: DPP-4 may inhibit endothelium-dependent NO-mediated dilation via superoxide production in the retinal arterioles. DPP-4 likely facilitates development of diabetic retinopathy by impairing endothelium- dependent NO-mediated vasoreactivity.

604-P Prevalence and Incidence of Cataracts in a Population of Yucatan Miniswines after Induction of Type I Diabetes CHRIS HANKS, ALYSSA INGERSON, MELISSA FREEMAN, SARAH SCHLINK, LAUREN DELANEY, SARAH M. RENNA, LARRY D. BROWN, ALAIN STRICKER- KRONGRAD, GUY F. BOUCHARD, Columbia, MO Cataracts as a consequence of chronic diabetes is considered a leading cause of legal blindness in humans in the United States and is also observed frequently in aged diabetic populations (>65%).

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Objective: Assess post-induction (PI) onset of clinical ocular cataract(s) in Quantitation of serum Rhodopsin was performed at protein level using a a colony of over 266 castrated, male, diabetic, Yucatan miniature swine. commercially purchased sandwich ELISA (Human Rhodopsin (RHO) ELISA kit, Methods: Diabetic miniature swine were routinely screened by a Cusabio Biotech Co. ®, P. R. China). Rhodopsin was measured in serum from veterinarian for clinical ocular abnormalities including visible “mature” 40 patients with diabetes and various degrees of DR and 40 healthy age cataracts. and gender-matched control persons. Both groups of patients were selected Results: Over the course of a 6 month period, the prevalence was 30 % from our local diabetes database and biobank which currently contains (138 cataracts in 80 animals). The most recent incidence (past 2.5 month) blood and urine from approximately 4,000 patients with diabetes and 5,000 was 20 % (38 animals with 60 positive eyes from 186 negative animals). 18 healthy control persons, collected from the area of Lillebaelt Hospital with POSTERS animals had bilateral and 30 animals had unilateral cataracts (OD: 31; OS: 400.000 inhabitants. Of the 40 patients with diabetes and a DR diagnosis, Complications

29). Cataract onset ranged from 2 to 19 months PI with an average of 11 there was an equal distribution of type 2 diabetic patients (n=20) and type 1 Acute and Chronic months PI. Cataracts were detected earlier in animals when euglycaemia (n=20) diabetic patients. was intentionally less controlled, which supports the current predominant For healthy controls the median Rhodopsin concentration was 8.1 ng/L theory of glycation-induced cataract development. Interestingly, swine (95% reference interval 5.2 -10.4 ng/L), and for patients with diabetes and unlike human are not capable of glycating their hemoglobin due to the lack DR the median Rhodopsin concentration was 18.6 ng/L (95 % range 11.0 - of penetration of glucose into the red cells. Miniswine with cataracts appear 22.6), p-value 0.0009. to function acceptably well despite the assumed visual handicap. In conclusion, Rhodopsin may be a marker for DR. Conclusions: Diabetic Yucatan miniature swine commonly manifest with cataracts on average at 11 months post-induction. Insulin regimen 607-P and glucose control are strong factors in the prevalence and incidence of Reduced Beta2-Glycoprotein I Inhibits Oxygen-induced Retinal cataracts in diabetic miniswines. Our data also suggests that the glycation Angio genesis in Neonatal Mice Through Vascular Endothelial of swine lenses readily occurs due to the high incidence of cataracts in Growth Factor Pathway diabetic animals with non-optimal glucose control. In addition the diabetic PEI YU, HONGYAN LIU, DEMIN YU, SAIJUN ZHOU, RUI CHEN, ZEJUN MA, Tianjin, miniswine would provide a good model for preventative or therapeutic China cataract therapies. The beta2-glycoprotein I (β2GPI), also known as apolipoprotein H, is a phospholipid-binding plasma protein that consists of fi ve homologous 605-P repeated units, down-regulateing VEGF signaling pathways and inhibiting Prevention of Diabetic Retinopathy in Patients with Type 2 Diabetes angiogenesis in vitro. However, in vivo roles and effectors of reduced β2GPI by Multifactorial Target Control: A Four-Year Prospective Study and β2GPI in retinal angiogenesis are not explicitly clear. We made oxygen- WENXIA WU, MENG REN, CHUAN YANG, LI YYAN, Guangzhou, China induced retinopathy to investigate the effects of reduced β2GPI and β2GPI. Objective: A longitudinal prospective study was undertook to investigate Retinal neovascularization was evaluated with histologic quantitation, the effect of intensifi ed multifactorial target control on diabetic retinopathy immunohistochemistry analysis and the angiography, and the expression of in patients with type 2 diabetes. VEGF, VEGFR-1, VEGFR-2 and HIF-1 mRNA and the phosphorylation of ERK Research Design and Methods: 144 type 2 diabetic patients, without and Akt were detected by real-time PCR or Western blot. We showed that previous microvascular or macrovascular complications, were randomized retinal neovascularization was signifi cantly observed in the mice of PBS into an intensive intervention group and a conventional intervention group group. Both β2GPI and reduced β2GPI inhibited retinal neovascularization with the ratio of 3:1. The intensive group (110) received multifactorial inter- (P<0.01), with the effect of the reduced β2GPI being signifi cantly stronger vention, with pharmacologic therapy targeting hyperglycemia, hyper tension, (P<0.05). The expression of VEGF, VEGFR-1, VEGFR-2 and HIF-1 mRNA dyslipidemia, along with primary prevention of vascular disease with in PBS group was increased (P<0.05). β2GPI and reduced β2GPI inhibited aspirin when necessary according to the ADA recommendation. While the this increase (P<0.05), with the effect of reduced β2GPI being signifi cantly conventional group (34) was assigned to receive conventional treatment. stronger (P<0.05). Compared to normal group, the phosphorylation of ERK1/2 Patients were followed up for 4 years. The primary outcomes was the time to and Akt was increased (P<0.05), β2GPI and reduced β2GPI inhibited this the fi rst occurrence of retinopathy. The secondary outcome was the severity increase (P<0.05), the latter is more severe. So both β2GPI and reduced of diabetic retinopathy. β2GPI inhibited retinal angiogenesis, they performed this action by down- Results: 93 in the intensive group and 32 in the conventional group regulating the expression of VEGF and its downstream key molecules. They completed the 4-year follow-up. During the follow-up,the control of serum may have potential anti-angiogenic activity in vivo. lipid was lower in the intensive group than in the conventional group (P<0.05). While the mean level of blood pressure and glucose between the two 608-P groups did not differ signifi cantly (P>0.05). The percentage of use of aspirin Changes in Retinal Blood Flow and Risk of Developing Diabetic in intensive group was higher than in conventional group (94.6 vs. 26.9, Retinopathy in Patients with Type 2 Diabetes p<0.0001). Finally, diabetic retinopathy occurred in 19 cases in the intensive TAIJI NAGAOKA, EIICHI SATO, ATSUSHI TAKAHASHI, KENJI SOGAWA, group and 7 cases in the conventional group for a cumulative prevalence of HARUMASA YOKOTA, TSUNEAKI OMAE, AKITOSHI YOSHIDA, Asahikawa, Japan 18.7% and 21.7%, respectively (P=0.679).No signifi cant differences between Purpose: To examine the prospective association between retinal blood the two groups were observed regarding severity of diabetes retinopathy fl ow (RBF) and the risk of diabetic retinopathy in patients with type 2 (P=0.780). diabetes. Conclusion: Our study found that intensive control of serum lipid and Methods: This was a prospective hospital-based study of 106 patients primary prevention of vascular disease with aspirin could not reduce the risk with type 2 diabetes with no diabetic retinopathy at baseline. The RBF was of development of diabetic retinopathy. measured in both eyes of each patient. The 5-year incidence of diabetic Supported By: National Key Basic Research Development Project (2006 retinopathy was ascertained from retinal photographs obtained at annual BAI0) follow-up visits. The RBF was measured in the temporal retinal arterioles using laser Doppler velocimetry at baseline and at the 1- and 5-year 606-P examinations. Rhodopsin in Blood—A Biomarker for Diabetic Retinopathy? Results: Thirty-six patients (34%) developed mild nonproliferative diabetic EVA R.B. PETERSEN, SØREN B. HANSEN, TINA PARKNER, CRAMER K. CHRISTEN- retinopathy during the follow-up period. The longitudinal changes in RBF SEN, IVAN BRANDSLUND, Vejle, Denmark were 12.9 ± 4.9% and 17.4 ± 6.3% in patients who developed retinopathy Diabetic retinopathy, DR, is the most frequent cause of blindness among and 3.2 ± 2.6% and 5.1 ± 3.3% in patients who did not develop retinopathy younger adults in the western world. DR leads to blindness in up to 5 % of at 1 and 5 years, respectively. There was a signifi cant (p < 0.05) difference in patients with type 1 and 2 diabetes. The incidence of DR increases with the the changes in RBF between both groups. duration of diabetes, thus after fi ve and twenty years of diabetes, 10 % and Conclusions: Our fi ndings showed that the longitudinal changes in RBF 60 %, respectively, has DR. No biomarkers currently exist to detect DR. were associated with development of diabetic retinopathy in patients with The aim of the study is to investigate whether Rhodopsin is a possible type 2 diabetes. The variability of the RBF in the retinal arterioles may be biomarker for the detection and grading of DR. Rhodopsin is a protein receptor associated with the pathogenesis of diabetic microvascular complications. containing a light sensitive pigment in the cells of the retina, solely located Supported By: Grants-in-Aid for Scientifi c Research (B25293352) in the cell membrane of the rods. If exposed to hypoxia or ischemia as in DR, the retinal cells decay and this may lead to the release of Rhodopsin.

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A155 DIABETIC DYSLIPIDEMIA

609-P diabetes attending diabetic retinopathy services at the Pacifi c Eye Institute Platelet Indices and Fibrinogen May Forecast the Diabetic Retino- in Suva, Fiji. Their initial photo-screening visit occurred between October pathy (DR) in Type 2 Diabetes Mellitus (T2DM) and December 2009, shortly after limited resource diabetic eye services YAN-MING CHEN, XI-XIANG TANG, PAN-WEI MU, QIU-JU LU, MAN-MAN were established. Patients were identifi ed using the computerised database WANG, JIONG SHU, LONG-YI ZENG, Guangzhou, China and information was extracted regarding demographics, diabetes type, The study was to investigate the relationship between platelet indices, initial vision, initial retinopathy grading, treatment, compliance with follow- fi brinogen (FIB) and DR in T2DM. According to retinopathy, 147 newly diagnosed up, response to therapy and visual outcomes. 456 patients were included in the initial cohort. A high percentage (29%, 133 patients) presented with

POSTERS T2DM were divided into 3 groups: without retinopathy (DM, n=72), with non-

Complications proliferative DR (NPDR, n=45) and with proliferative DR (PDR, n=30). Sixty controls advanced retinopathy; in many cases, unamenable to treatment. Outcomes Acute and Chronic (NC) were also enrolled. Compared with NC, levels of fasting plasma glucose (FPG), from 224 patients (49%) remaining in attendance in 2012-13 were analysed. hemoglobin A1c (HbA1c), Mean platelet volume (MPV), Platelet distribution width Patients presenting with mild or no retinopathy carried a good prognosis, with (PDW) and FIB in all diabetes patients (DM, NPDR and PDR) were remarkably 77% remaining stable. Just 3.7% of this subgroup required laser, which was increased (P<0.05), while Platelet count (PLT)Plateletcrit (PCT) were decreased successful in all but one patient. Patients presenting with sight threatening (P<0.05). Levels of MPV, PDW and FIB in DR (NPDR and PDR) were higher but levels retinopathy carried a signifi cantly higher risk of retinopathy progression (45%) of PLT and PCT were lower than that in DM (P<0.05). No signifi cant difference was and of the 100 eyes that received laser, 16 continued to progress despite found in levels of FIB, PLT and PCT between NPDR and PDR. Whereas there was a treatment. Overall, treatment was successful in achieving the aim of conserving signifi cant difference in levels of MPV and PDW between NPDR and PDR. Positive vision or stabilising retinopathy in the majority of the cohort that attended correlation of MPV with PDW and FIB (r = 0.311, P<0.05) were found in diabetics. follow-up. Patients who presented with advanced retinopathy or visual loss Taken together the joint detection of FIB and platelet indices, especially MPV and did not regain vision with treatment. The results confi rm the effectiveness of PDW, can be used as indexes to predict the retinopathy in type 2 diabetes. the diabetic eye services in Suva, Fiji, showing that with screening, continued follow-up and laser therapy the majority of patients maintain good vision Table 1. Platelet Indices and Fibrinogen According to Diabetic Status. despite a limited resource context. We show that patients with less severe DM (n=72) NPDR (n=45) PDR (n=30) NC (n=60) retinopathy are most likely to benefi t from laser treatment and hope that this FPG(mmol/l) 9.5±3.0** 10.2±3.4** 11.8±4.3** 4.9±0.9 fi nding will help guide future resource allocation. HbA1C(%) 10.2±3.1** 11.0±3.2** 10.1±2.6** 5.0±0.5 PLT(*10e9/l) 165.2±51.7* 138.6±45.2**Δ 145.3±43.5**Δ 201.5±52.3 DIABETIC DYSLIPIDEMIA PCT(%) 0.18±0.05* 0.13±0.04*Δ 0.14±0.06*Δ 0.22±0.04 MPV(µm3) 10.75±2.04* 12.11±2.01*Δ 14.43±2.3**Δ 9.54±1.52 Guided Audio Tour: Clinical Lipidology Update—New Treatments, Statin PDW(%) 16.05±1.56* 17.21±1.42*Δ 18.12±1.23**Δ 13.72±1.21 Safety, Side Effects, and Epidemiology (Posters: 612-P to 619-P), see page 17. * *Δ *Δ FIB(g/l) 3. 74±1.6 4.71±1.9 4.8±2.1 2.62±1.7 & 612-P Supported By: Natural Science Foundation of Guangdong Province Statins and Glycemic Control in Diabetes: A Meta-analysis (S2013010015931) SEBHAT ERQOU, CHRISTINE LEE, AMANDA I. ADLER, New York, NY, Toronto, ON, Canada, Cambridge, United Kingdom 610-P Current evidence indicates that statins increase the risk of incident Upregulation of Cx43 Expression Rescues Retinal Müller Cells diabetes; however, the relationship between statins and glycemic control (rMCs) from HG-induced Apoptosis in people with established diabetes has not been well-characterized. We DONGJOON KIM, TETSUYA MUTO, SAYON ROY, Boston, MA conducted a meta-analysis of randomized controlled trials (RCT) of statins Gap junction intercellular communication (GJIC) is an essential process for and cardiovascular or other intermediate outcomes in diabetic patients, maintenance of cellular function and survival. Previously we have shown that HG with available data on glycemic control. We identifi ed studies published reduces Cx43 expression, inhibits GJIC, and promotes rMC apoptosis associated through November 2013 by searching electronic databases and reference with diabetic retinopathy (DR). In this study, we examined if upregulation of Cx43 lists. We included RCT in which the intervention group received statins rescues Müller cells from HG-induced apoptosis, and if decreased Cx43 in Müller and the control group received placebo, with >200 participants enrolled, cells contributes to retinal pericyte apoptosis. rMCs were grown in normal (5 mM with intervention lasting >12 weeks, and with pre- and post- intervention glucose; N) or HG (30 mM glucose) medium for 7 days. In parallel, cells were grown hemoglobin A1c (HbA1c) reported. In a pooled analyses of eight trials in HG medium and transfected with plasmid pEGFPN1 containing full-length Cx43 involving 9479 participants and an average follow-up of 3.9 years, the cDNA or empty vector as control. Cx43 upregulation in the transfected cells were mean HbA1c of participants randomized to statins was higher than those determined using western blot (WB) analysis, and changes in GJIC were assessed randomized to placebo [mean difference: 0.12% (1.31 mmol/mol) (95% using scrape loading dye transfer (SLDT) assay. A differential staining method was CI 0.04%-0.19%, p=0.038)], with a trend towards a stronger effect for used to identify apoptotic cells. Additionally, rMCs transfected with Cx43 siRNA or atorvastatin than pravastatin. There was modest heterogeneity (I2 =49%, scrambled siRNA and grown as cocultures with retinal pericytes were assayed for p=0.004) not explained by study-level characteristics. This review was apoptosis. WB analysis showed signifi cant Cx43 upregulation in cells transfected limited by the small number of studies, available data on only two statins, with pEGFPN1 and signifi cant Cx43 downregulation in cells transfected with and sparse reporting on changes in use of anti-diabetic medications. In Cx43 siRNA compared to untransfected cells. Importantly, the inhibitory effect conclusion, statin treatment may lead to a modest increase in HbA1c in of HG on Cx43 expression was abrogated in pEGFPN1-transfected cells grown patients with diabetes. in HG. Similarly, SLDT analysis indicated that HG-induced decrease in cell-cell communication was normalized in cells transfected with pEGFPN1 and grown in HG. As expected, cells grown in HG showed signifi cant increase in the number of apoptotic cells. Interestingly, normalization of Cx43 expression in the Cx43 plasmid-transfected cells resulted in rescue of the HG cells from apoptosis, and downregulation of Cx43 in the Cx43 siRNA-transfected rMCs induced apoptosis in pericytes in the cocultures. In conclusion, Cx43 upregulation rescues rMCs from HG-induced apoptosis by improving GJIC activity; a potential strategy against Muller cell loss in DR. Supported By: NEI; NIH 611-P Four-Year Outcomes from a Limited Resource Diabetic Retinopathy Service: The Pacifi c Eye Institute Diabetic Retinopathy Service, Suva, Fiji ERIKA M. DAMATO, NEIL MURRAY, RINKI MURPHY, TELATIA BIU SIKIVOU, JOHN SZETU, CHARLES N.J. MCGHEE, Auckland, New Zealand, Suva, Fiji We carried out a retrospective observational cohort study with the aim of reporting four year visual and treatment outcomes for a cohort of patients with

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& 613-P Adverse Reactions to Statins and Discontinuation of Statin Therapy in Patients with Diabetes in Routine Care Settings HUABING ZHANG, JORGE PLUTZKY, STEPHEN SKENTZOS, FRITHA MORRISON, PERRY MAR, MARIA SHUBINA, ALEXANDER TURCHIN, Beijing, China, Boston, MA Many patients with diabetes do not take statins, despite abundant evidence of benefi t. This is thought to be at least in part due to the high POSTERS

rates of adverse reactions(ARs) to statins reported in routine care settings. Complications

Rigorous studies of management of ARs to statins in routine care settings Acute and Chronic are therefore needed. We conducted a retrospective cohort study of ARs to statins (statin-related events SREs) in patients with diabetes at outpatient practices affi liated with two academic hospitals between 01/01/2000 and 12/31/2009. Information on statin ARs was obtained from a combination of structured EMR entries and analysis of electronic provider notes by validated natural language processing software. Among 28,445 diabetic patients who were prescribed statins during the study period, SREs were documented for 4,053 (14.2%). More than a quarter (28.9%) of ARs were myalgias or myopathy. Over half (2,441 / 60.2%) of the patients who had a SRE had the statin discontinued at least temporarily. Of these, 1,586 (65.0%) patients were re- challenged with a statin over the subsequent 12 months. The majority of patients who were re-challenged (91.6%) were still taking a statin 12 months after the SRE. Among the 690 patients who were re-challenged with the same statin to which they had an SRE, 309 (44.8%) were on the same statin 12 months later, 277 of them on the same or higher dose. After adjustment for confounders, patients who had a mild (≥ 3-fold) CK or LFT elevation were at a higher risk both for statin discontinuation and not being re-challenged after discontinuation. However, among patients who were re-challenged, neither CK nor LFT elevation was predictive of long- term discontinuation. In this large retrospective study SREs in diabetic patients were common and often led to their discontinuation. However, the majority of patients who are re-challenged were able to take statins (even the same ones to which the original AR was ascribed) long-term. Supported By: NLM; DAREF; China NKPCS; Peking Union Medical College & Hospital 615-P Increased ApoB/A1 Ratio Predicts the Deterioration of Glucose Homeostasis Independently of Insulin Sensitivity & 614-P ANDREA NATALI, SIMONA BALDI, FABRICE BONNET, MENSUD HATUNIC, Effects of Long-term, Monthly Administration of the PCSK9 Inhibitor ANDREA MARI, BEVERLEY BALKAU, ELE FERRANNINI, RISC INVESTIGATORS, Evolocumab in Patients with Dysglycemia or Metabolic Syndrome Pisa, Italy, Rennes, France, Dublin, Ireland, Padova, Italy, Villejuif, France ROBERT R. HENRY, RURY R. HOLMAN, ROBERT P. GIUGLIANO, FREDERICK J. Elevated ApoB and reduced ApoA1 levels are features of the metabolic RAAL, DAVID SULLIVAN, NARIMON HONARPOUR, PATRIC NELSON, MARY syndrome and in some studies predicted development of type 2 diabetes ELLIOTT, THOMAS LIU, SCOTT M. WASSERMAN, MICHAEL J. KOREN, San Diego, (T2D). Whether these apolipoproteins are associated with T2D risk CA, Oxford, United Kingdom, Boston, MA, Johannesburg, South Africa, Camperdown, independently of insulin resistance has not been determined. Australia, Thousand Oaks, CA, Cambridge, United Kingdom, Jacksonville, FL Glucose tolerance (OGTT) and ApoB and ApoA1 concentrations were Patients with dysglycemia benefi t from statins; however, high-intensity measured at baseline and after a follow up of 3.5 yrs in a cohort of statins negatively impact glucose metabolism. We investigated the effects nondiabetic subjects (554 women and 456 men); baseline insulin sensitivity of evolocumab (AMG 145), a fully human monoclonal antibody against PCSK9 (M/I) was measured by a euglycemic hyperinsulinemic clamp), and β-cell that effectively reduced LDL-C in phase 2 trials, in patients with dysglycemia glucose sensitivity (β-GS) was obtained from mathematical modeling of or metabolic syndrome (MetS). OGTT plasma glucose and C-peptide responses. In the OSLER study, 1104 patients that participated in a parent study In women and men, baseline ApoB/A1 ratio was associated with BMI were randomized to evolocumab (EvoMab) 420 mg monthly with standard (r=0.16 and 0.24), waist/hip ratio (WHR, r=0.12 and 0.19), fasting (r=0.09 and of care (SOC) or SOC for 1 year. Of the OSLER patients with type 2 diabetes 0.11) and 2-h glucose (r=0.11 and 0.16), fasting (r=0.21 and 0.32) and 2-h insulin mellitus (T2DM; n = 109), impaired fasting glucose (IFG; n = 134), or MetS, (r=0.11 and 0.21), triglycerides (r=0.49 and 0.63) and HDL cholesterol (r=-0.31 n = (425), 90, 112, and 337, respectively, had an observed week 48 LDL-C and -0.34), mean blood pressure only in women (r=0.15) and M/I (only in men, value. Mean (SE) LDL-C changes from parent-study baseline at week 48 in r=-0.28). Unexpectedly, the ApoB/A1 ratio was positively related to fasting OSLER patients on EvoMab + SOC were -46 (3)% (T2DM); -51 (3)% (IFG); glucagon (r=0.19), while no association was present with β-GS in either and -54 (1)% (MetS). In the SOC-alone arm, changes were -5 (4)% (T2DM); sex. At follow-up, 130 subjects (13.1%) showed a deterioration of glucose 2 (4)% (IFG); and -3 (2)% (MetS). Adverse event (AE) rates for patients homeostasis (from NFG to IFG or IGT or diabetes), in association with an with T2DM, IFG, or MetS were 76% (EvoMab + SOC in OSLER) and 71% increase in BMI and WHR, and a decrease in both M/I and β-GS; in contrast, (SOC alone); serious AEs occurred in 8% and 7% of patients, respectively. baseline lipids and ApoB/ApoA1 ratio did not change signifi cantly with time. EvoMab + SOC patients showed no signifi cant changes in FPG or HbA1C In a multivariate logistic model, progression to dysglycemia was predicted compared to the SOC arm (Fig. 1). by the ApoB/ApoA1 ratio (odds ratio +1SD=2.3[1.4-3.6]) independently of sex, Monthly EvoMab reduced LDL-C in patients with dysglycemia or MetS and age, WHR, fasting and 2-h glucose, M/I, and β-GS. was well tolerated with no change in glycemic control. We conclude that an increased ApoB/ApoA1 ratio predicts deterioration of glucose tolerance independently of traditional risk factors and insulin resistance. The mechanisms of this association remain to be clarifi ed. Supported By: European Union; AstraZeneca

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A157 DIABETIC DYSLIPIDEMIA

& 616-P & 618-P Rosemary Extracts Inhibit Apolipoprotein B48 Secretion in Primary The Arg59Trp Mutation in ANGPTL8 (Betatrophin) Is Associated with Enterocytes and Intestinal Porcine Epithelial Cells Total Cholesterol Concentration in American Indians and Mexican BOLIN QIN, LANG QIN, AIPING ZHAO, RICHARD A. ANDERSON, CHAO LIU, Americans and Differentially Affects Cleavage of ANGPTL3 Baltimore, MD, Beltsville, MD, Edgewater, MD, Nanjing, China JOHANNA DISTEFANO, MATTHEW TAILA, FATJON LETI, MARK ZHANG, Rosmarinus offi cinalis (rosemary) has been shown to exert antidiabetic MAHDIEH KHOSROHEIDARI, ELENA EDDY, SAYUKO KOBES, WILLIAM C. effects and to help control dyslipidemia. Dyslipidemia is a complex cluster KNOWLER, SOBHA PUPPALA, JOANNE E. CURRAN, MELANIE CARLESS, DONNA POSTERS

Complications of potentially atherogenic lipid and lipoprotein abnormalities including M. LEHMAN, JOHN BLANGERO, RAVINDRANATH DUGGIRALA, ROBERT L.

Acute and Chronic intestinally derived apoB-48-containing chylomicrons, which play an HANSON, Phoenix, AZ, San Antonio, TX important role in postprandial lipid metabolism in the insulin resistant We previously identifi ed a locus linked to fasting serum total cholesterol (TC) state. However, it is not known whether rosemary extract (RME) modulates concentration in Pima Indians on chromosome 19p (LOD=3.89). Subsequent apoB48 secretion directly. Freshly isolated primary enterocytes of high fi ne-mapping of this region using 346 single nucleotide polymorphisms fructose feeding-induced insulin resistant Syrian golden hamsters treated (SNPs) genotyped in Pima Indians reduced the linkage interval from 90 cM with RME (10µg and 100µg/mL) for 12 hours were shown, by immunoblotting, to 15.7 cM, which spans 19p13.1-p13.3 and contains 229 genes. To identify to inhibit apoB48 secretion into media. RME also reduced the secretion of trait-associated SNP alleles, we genotyped 1536 markers within the region apoB48 in differentiated intestinal porcine epithelial cells (iPEC-1). RME of interest in 1884 Pima Indians and analyzed association with log(TC). The enhanced cellular SIRT1protein expression by immunofl uorescence and strongest evidence for association with TC concentration was found with immunoblotting also showed SIRT1 protein levels were upregulated by rs4804576 (increase of 4.2% per copy of the C allele; P=2.0 x 10-7) located RME in IPEC-1. Moreover, SIRT1 inhibitor IV diminished RM’s effects on in the DOCK6 (dedicator of cytokinesis 6) gene and rs2278436 (4% increase apoB48 secretion. We also investigated the effects of RME on infl ammatory per copy of the G allele; P=5.0 x 10-6) in the ANGPTL8 (angiopoietin-like 8 and lipogenic factors, which both have been linked to the SIRT1 signaling and also known as betatrophin) gene. We evaluated the most strongly pathway. Phosphor-NF-κB-p65, TNF-α, protein tyrosine phosphatase 1B, associated markers in 2413 Mexican American participants of the SAFS and and microsomal triglyceride transfer protein levels were all decreased by found the strongest evidence for association with rs2278436 (2% increase RME. Interestingly, RME also regulated Clock (circadian locomotor output per copy of the G allele; P=0.0058). The variant allele at rs2278436 predicts cycles kaput), Bmal1 (brain and muscle Arnt-like protein 1) expression, the an Arg59Trp substitution and has previously been associated with LDL-C key components of the mammalian circadian clock, which have been linked and HDL-C in four populations. In Pimas and Mexican Americans, rs2278436 to multiple diseases, such as obesity and diabetes. In summary, our results was also associated with HDL-C (P=0.0007 and 0.00002, respectively). In suggest that rosemary extract attenuates intestinal apoB48 secretion, vitro, ANGPTL8 transcript and protein levels increased in response to 100 nM in part, through SIRT1 activation and may also be involved in circadian insulin (P=0.0001), and transcript, but not protein, levels increased with high regulation. (25 mM) glucose (P= 0.05). ANGPTL8 activates ANGPTL3, which regulates Supported By: IN Ingredients Research Foundation fatty acid metabolism. The variant allele decreased cleavage of ANGPTL3 in Hep G2 cells. These fi ndings suggest that rs2278436 contributes to & 617-P increased activation of ANGPTL3 by ANGPTL8 and lend support to the idea The Effects of Intensive Diabetes Therapy on Nuclear Magnetic that inhibition of ANGPTL8 may provide a novel therapeutic strategy for Resonance-determined Lipoprotein Subclass Profi les in Type 1 reducing plasma lipoprotein levels. Diabetes in the Diabetes Control and Complications Trial (DCCT) Supported By: NHLBI YING ZHANG, ALICIA J. JENKINS, ARPITA BASU, JULIE A. STONER, MARIA F. LOPES-VIRELLA, RICHARD L. KLEIN, TIMOTHY J. LYONS, THE DCCT/EDIC & 619-P RESEARCH GROUP, Oklahoma City, OK, Sydney, Australia, Stillwater, OK, Charleston, Evolution of LDL-C in Type 1 Diabetes: The SEARCH for Diabetes in SC, Belfast, United Kingdom Youth Study The Diabetes Control and Complications Trial (DCCT) demonstrated that AMY S. SHAH, DAVID M. MAAHS, JEANETTE M. STAFFORD, LAWRENCE M. intensive management of Type 1 diabetes reduces risk for cardiovascular DOLAN, WEI LANG, GIUSEPPINA IMPERATORE, RONNY A. BELL, ANGELA D. complications, but the effect of the intervention on detailed plasma LIESE, KRISTI REYNOLDS, CATHERINE PIHOKER, SANTICA M. MARCOVINA, lipoprotein subclasses has not been defi ned. DANA DABELEA, FOR THE SEARCH FOR DIABETES IN YOUTH STUDY GROUP, We determined nuclear magnetic resonance lipoprotein subclass profi les Cincinnati, OH, Aurora, CO, Winston-Salem, NC, Atlanta, GA, Columbia, SC, Pasa- (NMR-LSP) (i.e. molar subclass concentrations and mean particle diameters) dena, CA, Seattle, WA in 1,294 DCCT study subjects fi ve years (range 2 - 9 yrs) after randomization Little is known about the natural evolution of LDL-cholesterol (LDL-C) to intensive vs. conventional glycemic management. In cross-sectional in youth with type 1 diabetes (T1D). Understanding the characteristics of analyses, we compared data from the two DCCT randomization groups, participants in whom LDL-C progresses, regresses or remains abnormal may stratifi ed by sex. help guide treatment. As previously described for the entire DCCT cohort, standard LDL- and We studied 1012 T1D youth (initial mean age 10.4 years, 50% female, HDL-cholesterol measures were not altered by intensive management, 80% non-Hispanic white (NHW), not on lipid lowering drugs) participating while triglyceride levels were lowered. NMR-LSP showed that in women, in SEARCH with ≥2 fasting lipid measurements over a period of 7 years. compared with conventional therapy, intensive therapy was associated with Progression was defi ned as normal baseline LDL-C with abnormal LDL-C lower concentrations of large VLDL & chylomicrons combined (median of 0.8 at follow-up (LDL-C>100mg/dl). Regression was defi ned as abnormal vs. 1.0 nmol/L, p=0.03), total IDL/LDL (mean of 973 vs. 1045 nmol/L, p=0.01), baseline LDL-C with normal LDL-C at follow-up. Groups were compared small HDL (mean of 15.9 vs. 17.6 µmol/L, p=0.0009), and total HDL (mean of for demographics and derived measures (area under the curve (AUC)) for 34.8 vs. 36.2 µmol/L, p=0.01) particles. In contrast, in men, intensive therapy metabolic predictors that change over time (A1c and BMIz) using t-tests/ was associated only with a reduction in small HDL (mean of 18.5 vs. 19.3 chi-square tests. µmol/L, p=0.03). When both sexes were combined, signifi cant differences LDL-C progressed in 17%, regressed in 13%, was stable abnormal in resembled those in women alone, and intensive management was also 21%, and stable normal in 50% (Table). Risk factors for LDL-C progression associated with larger LDL particle diameter (20.7 vs. 20.6 nm, p=0.01). were older age at T1D diagnosis, female sex, and a higher A1c AUC. Factors Intensive diabetes therapy alters lipoprotein subclass characteristics, associated with LDL-C regression were NHW race-ethnicity, male sex and affecting not only triglyceride-rich VLDL, but also HDL and IDL/LDL. Further lower BMIz and A1c AUC. research will determine why responses differ between men and women, Our data suggest A1c and BMI are modifi able risk factors that infl uence and whether the favorable changes contribute to the benefi cial effects the progression of dyslipidemia. Strategies focused on glucose and weight of intensive management of Type 1 diabetes on the development of control may have benefi cial impact on LDL-C regression in T1D youth. complications. Supported By: ADA (7-12-CT-46); NIH (5R01DK080043-02)

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621-P LDL-C Progression Stable p value Regression Stable p value normal abnormal Effect of Carvedilol on Metabolic Control in Patients with Type 2 Diabetes Mellitus and Resistant Hypertension n (% of total) 168 (16.6) 505 (49.9) 130 (12.9) 209 (20.7) IOANNA ZOGRAFOU, BARBARA NIKOLAIDOU, THEODORA GRIVA, ELENI Age in years at T1D diagnosis 10.9 ± 3.5 9.8 ± 3.5 <0.001 8.4 ± 4.2 9.0 ± 4.4 0.215 GAVRIILAKI, MICHAEL DOUMAS, CHRISTOS SAMPANIS, Thessaloniki, Greece Vasodilating b blockers possess a better metabolic profi le than traditional Male 75 (44.6) 272 (53.9) 0.038 69 (53.1) 85 (40.7) 0.026 b blockers. However, limited data exists on whether this benefi cial metabolic Non-Hispanic White 129 (76.8) 413 (81.8) 0.157 110 (84.6) 157 (75.1) 0.038

profi le is maintained in diabetic patients with resistant hypertension who POSTERS AUC: HbA1c 3212 ± 483 3060 ± 467 <0.001 3014 ± 420 3254 ± 509 <0.001 are already on diuretic therapy. We aimed, therefore, to evaluate the effect Complications Acute and Chronic AUC: BMI z-score 7525 ± 287 7484 ± 296 0.119 7425 ± 340 7593 ± 320 <0.001 of carvedilol, a vasodilating b blocker, on metabolic control in patients with type 2 diabetes mellitus (T2DM) and resistant hypertension. Fifty-one Stable normal is defi ned as normal at baseline and normal at f/u; Stable abnormal is defi ned as abnormal at baseline and abnormal at f/u; AUC: consecutive patients (15 male and 36 female) of age 51 to 84 years old (mean (Area Under the Curve) incorporates baseline and follow-up visits and 68) with T2DM (duration 14 years, range 15-31.7 years) and blood pressure adjusts for time. (BP) > 130/80 mmHg were studied. All patients were already receiving combination therapy of at least 3 antihypertensive drugs, including a Supported By: CDC; NIDDK diuretic, when carvedilol was added. Patients were followed up for 6 months. Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart 620-P rate (HR), body mass index (BMI), HbA1c and lipids (TCHOL, Tg, HDL-C, LDL-C) Low Total Cholesterol, Low LDL, Low HDL, High Risk: The Signifi - were determined at baseline and after 6 months of therapy with carvedilol. cance of Isolated Low HDL in African Men A signifi cant drop in TCHOL (194 ± 58.8. vs. 178.8 ± 49.1 mg/dl, p<0.0001) MICHELLE Y. O’CONNOR, CAROLINE K. THORESON, MADIA RICKS, STEPHANIE T. and Tg (154.31 ± 34.9 vs. 133.96 ± 42.1 mg/dl, p<0.0001) was found, whereas CHUNG, ANNE E. SUMNER, Bethesda, MD there was a non signifi cant change in HDL-C (50.8 ± 10.2 mg/dl vs. 50.3 ± 9.5 Despite a high rate of cardiometabolic disease, African descent mg/dl, p=NS), LDL-C (111.9 ± 40.6 mg/dl vs. 105.6 ± 43.2 mg/dl, p=NS) and populations often have a favorable lipid profi le. In Africans, it is unknown HbA1c (7.58 ± 1.16 % vs. 7,6 ± 1,13%, p=NS). Additionally, a signifi cant drop in whether low HDL-cholesterol (HDL-C) combined with low total cholesterol SBP (158.4 ± 13.5 vs. 148.9 ± 15.5 mmHg, p<0.001), DBP (86.6 ± 12.2 vs. 79.9 (T-CHOL) is indicative of cardiometabolic risk or simply a function of low ± 8.7 mmHg, p<0.001) and HR (86.7 ± 12.2 vs. 79.9 ± 11.3 bpm, p<0.001) was T-CHOL. In a cohort of 140 African men living in the United States, 87% noted. In patients with Type 2 Diabetes Mellitus and resistant hypertension had T-CHOL<200 mg/dL, but 59 (42%) had T-CHOL<150 mg/dL. Men with carvedilol seems to maintain its positive effect on metabolic control even T-CHOL<150 mg/dL, were divided into 2 groups according to HDL-C: <40 or when added to diuretics. Further major long-term clinical trials are needed ≥40 mg/dL and cardiometabolic risk factors were compared. Of the 59 men to prove the benefi cial effect of carvedilol over non selective b-blockers on with T-CHOL<150 mg/dL, all had LDL-Cholesterol (LDL-C)<100 mg/dL, but cardiovascular risk in these patients. 21 (36%) had HDL-C<40 mg/dL. Age and BMI did not vary by HDL-C group. However, men with HDL-C<40 mg/dL were more centrally obese (waist 622-P circumference: 92±8 vs. 86±12 cm, P=0.05, visceral adiposity (VAT): 133±64 Insulin Resistance in Younger Men Following Cardiac Bypass vs. 78±62cm3, P<0.01), less insulin sensitive (SI: 3.1±2.4 vs. 5.1±2.9, P=0.02) Surgery Is Linked to Dyslipidemia and Elevated ALT and had a higher prevalence of glucose intolerance (62% vs. 32%, P=0.02). ERA CATERINA MURZAKU, LOUIS F. AMOROSA, New Brunswick, NJ In addition, the low HDL-C group had higher LDL particle number, TG and Cardiopulmonary bypass surgery (CPB) is associated with marked insulin apoB levels and lower HDL size. Furthermore, as HDL-C declined, so did HDL resistance complicating postoperative glycemic control. We retrospectively size (r=0.8, Figure. Top Panel). In addition, LDL particle number correlated analyzed the insulin requirements of 179 men undergoing CPB. Unexpect- inversely with HDL-C (r=-0.6, Figure. Bottom Panel). Overall, in African men, edly, age was found to correlate inversely with the postoperative insulin the risk of low HDL-C is continuous even when T-CHOL and LDL-C is well requirement, (r = -0.22, p< 0.01). We further analyzed risk factors in younger within a favorable range. patients that might account for the greater than expected insulin requirement. The population was divided into two age groups by median age (67) with equally matched subgroups based on preoperative glycemic status: non-diabetic (A1c < 5.8%); prediabetic (A1c 5.8 to 6.5); and diabetic (A1c ≥ 6.5 or treated with oral agents). Men receiving insulin, TZD or GLP were excluded; all patients were treated with statins. The fasting serum glucose and A1c between younger and older age groups were 117±42 vs. 111±30mg/dl and 6.2±1.2 vs. 6.1±1.0, respectively. Pertinent metabolic variables are shown (all data mean±SD, *p < 0.001). The data indicate that younger patients have more hepatic fat as demonstrated by elevated ALT and more pronounced dyslipidemia with relatively increased non-HDL-c. These data suggest that disordered fat and cholesterol metabolism in younger patients may be associated with an adverse action of insulin and may contribute to accelerated cardiovascular disease necessitating cardiac surgery at a younger age. Age Group Weight ALT Total Cholesterol HDL-c Non-HDL-c Average age (n) (Kg) (IU/l) (mg/dl) (mg/dl) (mg/dl) <=6759+/-7*(78) 88+/-22 35+/-24* 157+/-39* 40+/-12 116+/-36* >6777+/-5*(79) 84+/-24 24+/-12* 137+/-27* 39+/-11 98+/-26*

623-P Atherogenic Dyslipidemia and Macroangiopathy Linked to Vitamin D Defi ciency in T2DM Patients MICHEL P. HERMANS, SOUMAÏLA CAMARA, SYLVIE A. AHN, MICHEL F. ROUS- SEAU, Brussels, Belgium, Paris, France Defi ciency of 25(OH)vitamin D (25(OH)D) is frequent in the general population and among T2DM patients. Atherogenic dyslipidemia (AD) is comorbid to T2DM, and is characterized by low HDL-C together with elevated fasting TG. In non-diabetics, an inverse association exists between 25(OH)D and fasting triglycerides (TG) levels. The aim of this study was to document how 25(OH)D defi ciency modulates the cardiometabolic phenotype of T2DM patients, particularly with respect to AD and macroangiopathy.

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A159 DIABETIC DYSLIPIDEMIA

298 T2DM patients (mean age (SD): 67 (11) years; diabetes duration 16 a short-term treatment with palmitic acid increased mitochondrial function (9) years) were divided into 2 groups according to 25(OH)D levels: a vitamin while long-term treatment decreased the mitochondrial function. Palmitic D-defi cient group, corresponding to the 1st 25(OH)D quartile [QI] (n=74; acid induced mitochondrial acetylation and PDH phosphorylation in a time- average vitamin D level 7 (2) ng/mL), and a second group composed of the dependent manner. Acetylation led to an increase in phosphorylation of PDH remaining 3 quartiles [QII-IV] of vitamin D (n=224), with 25(OH)D levels in the while increased phosphorylation did not affect mitochondrial acetylation low-to-normal range (mean 21 (9) ng/mL). level. Long-term acetylation led to suppression of PDH activity and reduction AD prevalence was 57% [QI] vs. 44% [QII-IV], ie a +30% relative increase in in mitochondrial function. Inhibition of β-oxidation in mitochondria prevented vitamin D-defi cient patients, in whom AD measures were signifi cantly worse: the acetylation and protected mitochondrial function. We conclude that free POSTERS

Complications (i) fasting TG: 207 (112) [QI] vs. 173 (110) mg/dL [QII-IV] (p 0.0224); (ii) remnant fatty acid transiently activates mitochondrial function through acetylation

Acute and Chronic cholesterol: 40 (19) [QI] vs. 33 (19) mg/dL [QII-IV] (p 0.0064); and (iii) the of mitochondrial proteins, and sustained acetylation leads to suppression atherogenic index of plasma [log(fasting TG/HDL-C)], a continuous measure of mitochondrial activity. Acetylation may inhibit mitochondrial function and of AD: 0.61 (0.32) [QI] vs. 0.51 (0.32) [QII-IV] (p 0.0204). Vitamin D-defi cient PDH activity through induction of phosphorylation. These results suggest patients had a signifi cantly much higher prevalence of macroangiopathies: that mitochondrial acetylation is induced by fatty acid β-oxidation and is 46% vs. 32% in [QII-IV], ie. a 44% relative increase (p 0.0371). By contrast, involved in competition of fatty acid and glucose in mitochondria. the two groups did not differ in age; gender; diabetes duration; BMI; fat Supported By: NIH (DK068036, DK085495 to J.Y.) mass; waist circumference; hypertension; metabolic syndrome; insulin sensitivity; hepatic steatosis; LDL-C; and apolipoprotein B100. Use of lipid- 626-P lowering drugs was similar in the 2 groups (statins; ezetimibe; fenofi brate): Prevalence of CVD Risk Factors Over Time among Youth with Type 81%; 4%; and 25% [QI] vs. 77%; 9%; and 21% [QII-IV]. 1 and Type 2 Diabetes Vitamin D-defi cient patients with T2DM are characterized by more severe GRACE KIM, JASMIN DIVERS, NORA FITZGERALD, DANA DABELEA, JEAN M. atherogenic dyslipidemia and higher rate of macroangiopathies. LAWRENCE, KRISTI REYNOLDS, RONNY A. BELL, ELIZABETH MAYER-DAVIS, TESSA L. CRUME, DAVID J. PETTITT, LENNA L. LIU, SEARCH FOR DIABETES IN 624-P YOUTH STUDY GROUP, Seattle, WA, Winston-Salem, NC, Aurora, CO, Pasadena, Prevalence of Statin-Intolerance and Its Impact on LDL-C, Non- CA, Chapel Hill, NC, Santa Barbara, CA HDL-C, and ApoB100 Target Attainment in T2DM From 1999–2000 to 2007–2008, NHANES reported that U.S. adolescents MICHEL P. HERMANS, SOUMAÏLA CAMARA, SYLVIE A. AHN, MICHEL F. ROUS- had no signifi cant changes in prevalence of hypertension and elevated low- SEAU, Brussels, Belgium, Paris, France density lipoprotein (LDL) cholesterol, but they had an increase in pre-diabetes Statins are widely prescribed to T2DM patients for primary or secondary and diabetes (DM) and a dose-response increase in rates of CVD risk factors cardiovascular prevention. A sizeable minority of statin-treated patients with overweight or obesity. We sought to determine if the prevalence of develop muscle-related intolerance (mostly myalgia and/or reversible CPK CVD risk factors was changing among youth with DM in the SEARCH Study elevation), often prompting dose reduction, statin switch, combination lipid- over a comparable time period. lowering drugs (LLD), or permanent statin withdrawal. This study assesses We examined the prevalence of CVD risk factors: hypertension (systolic the prevalence of muscle-related statin intolerance and its impact on lipids or diastolic BP ≥ 90%ile for age, sex and height, or taking medications), and lipoproteins target attainment. dyslipidemia (HDL ≤40mg/dl or TG ≥110mg/dl), and large waist circumference 648 T2DM patients (mean age (SD): 65 (9) years; diabetes duration 15 (WC) (≥90th%ile for age and sex) among youth with Type 1 (T1D, n=3507) and (9) years) were divided into 4 groups according to statin(s) (in)tolerance: Type 2 diabetes (T2D, n=547) newly diagnosed in 2002 through 2008 and (i) statin-tolerant [TOL] (n=587; 91%); (ii) statin-intolerant [INTOL] (n=61; stratifi ed by weight status (normal, OW, obese). 9%); among the latter, (iii) 44 patients kept on low-dose statins and/or In general, the prevalence of most individual CVD risk factors stratifi ed combination LLD [on-statin INTOL]; and (iv) 17 patients forever weaned from by age, gender, and ethnicity did not change signifi cantly over time in statins [off-statin INTOL]. youth with T1D or T2D. One exception was that the prevalence of large Use of statins; fi brates; and/or ezetimibe in [INTOL] was 73%; 22% and WC among youth T2D in youth ≥10 years old increased over time (66.0%- 31% vs. 100%; 19%; and 7% in [TOL]. Daily dose of statin was (mg): 15 83.6%, p<0.0001), with some consistency across gender and ethnic groups. (simvastatin); 13 (atorvastatin); 5 (rosuvastatin); and 22 (pravastatin) in [on- The prevalence of >2 CVD risk factors also did not change signifi cantly over statin INTOL]. time [T1D 7.1-10.5%, p=0.38 and T2D 66.3-73.3%, p=0.54]. The prevalence Among intolerant patients, there were signifi cant differences between of ≥2 CVD risk factors among youth with T1D was higher among those ≥10 [on-statin INTOL] and [off-statin INTOL] in CPK (259 (224) vs. 146 (97) year olds compared to 3-9 year olds (11.4% vs. 6.3%, p<0.0001) and those UI/L); hsCRP (0.26 (0.24) vs. 0.44 (0.35) mg/dL); aspirin (63% vs. 31%); and who were obese compared to those who were OW or normal weight (NW) benzodiazepines use (7% vs. 53%; all p <0.05), whereas no difference was (34.0% vs. 10.6% and 4.4%, respectively, p<0.0001). The prevalence of ≥ 2 recorded in age; gender; BMI; glucose-lowering therapies; BP; and micro- or CVD risk factors among T2D youth was higher in African Americans (61.6%) macroangiopathy. and Hispanics (74.8%) compared to NHW (31.4%, p=0.004), and those who Goal attainments (<70 mg/dL [LDL-C]; <100 mg/dL [non-HDL-C]; and <80 were obese (78.8%) compared to OW youth (58.7%, p<0.0001). mg/dL [apoB100]) were 38%; 35% and 46% in [TOL] vs. 30%; 28% and 45% The prevalence of most CVD risk factors did not change signifi cantly over in [INTOL], respectively. Among the latter; attainment rates were 41%; 39% time. However, about half the youth with diabetes have ≥2 CVD risk factors, and 55% in [on-statin INTOL] vs. 6%; 6%; and 24% in [off-statin INTOL], particularly those with OW or obesity. respectively. Supported By: CDC; NIH For such sizeable number of T2DM patients unable to keep statins and/or not meeting on-treatment LDL targets, there is a pressing need for innovative 627-P strategies beyond current statins. Paroxonase and Cholesterol Effl ux Activities in Type 1 Diabetes Subjects (T1D): Effect of High HDL 625-P JOSE LLINAS, ROSANNA CALDERON, ANGELA SZETO, SYLVIA DIAZ, THOMAS A. Mitochondrial Acetylation Induced by Palmitic Acid Beta-Oxidation HUGHES, RONALD B. GOLDBERG, ARMANDO MENDEZ, Miami, FL, Memphis, TN Leads to Mitochondrial Dysfunction High HDL-C (hHDL-C) is common in T1D, but whether it protects against YONG ZHANG, JIANPING YE, Baton Rouge, LA atherosclerosis is unknown. To investigate whether T1D with hHDL-C have Competition of fatty acids with glucose in mitochondria is a mechanism enhanced HDL functionality we assayed paroxonase (PON) as a measure of of insulin resistance as suggested by Randle theory. However, the exact the anti-infl ammatory properties of HDL and cholesterol effl ux (CEF), in 69 signal transduction by which fatty acids inhibit glucose utilization is still T1D subjects (mean+SEM age 47±2.2, duration 27.4±1.7y) and 43 healthy unknown. In this study, we examine mitochondrial acetylation and pyruvate controls (Co) (age 43±1.7y). PON was assayed by hydrolysis of paraoxon to dehydrogenase (PDH) activity as well as mitochondrial function in response p-nitrophenol, and CEF measured using apo B-free serum in 14C-cholesterol to fatty acid treatment in hepatocytes to understand the signal transduction preloaded J774 macrophages indexed to pooled plasma values. HDL was mechanism. We used 1C1C7 mouse hepatocyte cell line in this study. After separated by ultracentrifugation into low (HDL-LC), medium, (HDL-MC) and fatty acid treatment of the cells, mitochondria were isolated and the protein high density (HDL-HC) cholesterol subfractions. PON was lower in T1D than was examined by Western blot for acetylation and PDH phosphorylation. ATP, in C (172±10 vs. 204±11 U/L; p=0.042) but did not correlate with HDL-C or acety-CoA concentrations and PDH activity were determined in mitochondria. its subfractions. CEF when normalized by HDL-C (CEFn) was lower in T1D Seahorse was used to determine the mitochondrial function. We found that than Co (1.7±0.0 vs. 2.2±0.1, p<0.001) indicating reduced effl ux per unit HDL

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A160 DIABETIC DYSLIPIDEMIA in T1D. CEF correlated with HDL-C in T1D and Co (T1D: r= 0.59: C: r=0.42) 50 (8) years vs. 54 (11) years (p 0.0293). Low-Lp(a) patients had lower insulin and with HDL-LC and HDL-MC but not HDL-HC. When T1D were stratifi ed by sensitivity (39 (25)% vs. 58 (44)%; p 0.0031); lesser [BxS] (22 (14)% vs. 31 HDL-C >/<85th percentile of the Co HDL-C distribution to identify a hHDL-C (25)%; p 0.0102); and higher [BxS] loss rates (1.39 (0.35) %/year vs. 1.17 (0.44) subgroup, there were no differences in PON or CEF, but CEFn was decreased %/year; p 0.0112) than [QII-IV]. CVD-CAD prevalence was 32%-29% in [QI] in hHDL-C subjects (table * p<0.05). Thus both PON and CEFn are impaired vs. 59%-51% in [QII-IV] (p 0.0146 and 0.040, respectively). Left-handedness in T1D vs. Co, although overall CEF was not different. Importantly T1D with was much more frequent in [QII-IV] patients: 17% vs. 0% in low-Lp(a) (p hHDL-C do not show increased HDL functionality. 0.0261). Plasma Lp(a) levels were also modulated by laterality, being much higher (by 58%) in left-handed patients: 30 (25) mg/dL (median 21 [12-41] POSTERS

mg/dL) vs. 19 (22) mg/dL (median 11 [3-26] mg/dL) in right-handed patients Complications

(n=114; ie. 88%) (p 0.0238). Acute and Chronic Low plasma Lp(a) levels are linked to both insulin resistance and β-cell function loss, with earlier onset of T2DM. Beyond the expected association with CVD-CAD, higher plasma Lp(a) levels are also linked with left- handedness.

630-P PGC-1α Gly482Ser Polymorphism Contributes to NAFLD in Type 2 628-P Diabetes Mellitus (T2DM) Comparison of Goal-based vs. Percentage-based LDL Reduction YAN-MING CHEN, PAN-WEI MU, SHENG-QING HE, XI-XIANG TANG, XI-XIANG Amongst Diabetics TANG, MAN-MAN WANG, LONG-YI ZENG, Guangzhou, China JONATHAN H. WATANABE, MARK BOUNTHAVONG, TIMOTHY CHEN, La Jolla, Gly482Ser polymorphism of peroxisome proliferators-activated receptor γ CA, Seattle, WA, San Diego, CA coactivator-1α (PGC-1α) is associated with glucose and fat metabolism. The Background: The 2013 ACC/AHA Guideline on the Treatment of Blood study was to investigate the potential role of PGC-1α polymorphism in non- Cholesterol to Reduce Atherosclerotic Cardiovascular Risk recommend a alcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM). departure from the treatment to low density lipoprotein (LDL) goals in favor A total 480 subjects from Southern China were recruited and assigned of designated therapy based on risk grouping into Major Statin Benefi t into four groups: NAFLD complicated with T2DM (n=124), NAFLD without Groups. However, The Guideline treatment algorithm contains anticipated T2DM (n=116), T2DM without NAFLD (n=120), and normal glucose tolerance reductions in LDLs based on designated therapy. (NGT) (n=120). NAFLD patients, that included NAFLD with/without T2DM, Objective: We were interested in comparing the proportions of diabetic were more obese and insulin resistant than NGT subjects and T2DM. The patients that achieved percentage reduction goals versus the LDL-level frequency of Gly482Ser and/or Ser482Ser of PGC-1α in NAFLD complicated based goals previously targeted. with T2DM was higher than that in NGT subjects (P<0.05). Within all NAFLD Methods: The primary aim was to determine the percentages achieving patients, frequency of Gly482Ser and/or Ser482Ser of PGC-1α in NAFLD study endpoints of ≥ 50% reduction, ≥ 30% reduction, < 100 mg/dl, < 70 complicated with T2DM was also higher than that in NAFLD without T2DM. mg/dl 1 year after initiation of a statin medication for diabetic patients. Regression analyses indicated that dyslipidemia was a risk factor for NAFLD Separate dichotomous (yes/no) outcome variables were created to indicate complicated with T2DM. Objects who possessed this genotype (Gly482Ser whether each subject had reached ≥ 50% reduction, ≥ 30% reduction, < 100 polymorphism of PGC-1α), had lower plasma HDL-C levels,higher LDL-C mg/dl, < 70 mg/dl at end of 1-year study period. Data extracted from the levels and higher risk for NAFLD complicated with T2DM. Taken together Veterans Integrated System Network 22, a region which includes sites in Gly482Ser polymorphism of PGC-1α is associated with susceptibility of Southern California (Los Angeles, Long Beach, San Diego, Loma Linda) and NAFLD in T2DM. Las Vegas, Nevada. Patients were included if they were a new statin user Supported By: Natural Science Foundation of Guangdong Province (9151008901 between periods of November 30, 2006 and December 2, 2007. Differences 000092) in proportion achieving study endpoints was compared via Chi-squared test. All analyses performed using SAS 9.3 (Cary, NC). 631-P Results: 1,823 diabetic veterans were included in the analysis. For the Serum Triglyceride Levels Are Associated with Cytokeratin-18 primary aims for the ASCVD group, 37.74% achieved a 30% or greater drop Concentration in Patients with Type 2 Diabetes and Nonalcoholic in LDL from baseline; 10.42% achieved a 50% or greater drop in LDL from Fatty Liver Disease baseline; 57.87% were at an LDL level of 100 mg/dl or less at 1 year follow BARBARA IDZIOR-WALUS, MALGORZATA WALUS-MIARKA, ALEKSANDRA up; 17.94% were at an LDL level of 70 mg/dl or less at 1 year follow up. TROJAK, EWA WOZNIAKIEWICZ, JOANNA GASTOL, LUKASZ PAWLINSKI, Proportions were statistically different (P-value < 0.01). MACIEJ T. MALECKI, Krakow, Poland Conclusion: Goal-based versus percentage-based lipid reduction may Non-alcoholic fatty liver disease (NAFLD) is frequently observed in type 2 produce divergent proportions of patients deemed successful and/or diabetes. There is evidence that NAFLD is associated with insulin resistance infl uence subsequent treatment. and increased incidence of diabetic macroangiopathy. Cytokeratin 18 Supported By: University of California, San Diego (CK-18) is a biomarker of hepatic cell apoptosis and correlates with liver histopathology. 629-P The aim: to assess the associations between serum lipid concentrations Low Plasma Lp(a) Levels Are Related to Insulin Resistance, β-Cell and CK-18 in patients with NAFLD and type 2 diabetes. Material included Function Loss, and Right-Handedness in T2DM 76 consecutive patients, in whom secondary causes of liver disease were MICHEL P. HERMANS, SOUMAÏLA CAMARA, SYLVIE A. AHN, MICHEL F. ROUS- excluded. NAFLD was diagnosed by ultrasonography, CK-18 by ELISA, serum SEAU, Brussels, Belgium, Paris, France lipids enzymatically, glycated hemoglobin A1c by HPLC. The mean age of Lipoprotein(a) [Lp(a)] is the strongest genetic risk factor for CVD. By patients was 60.9+/-10.1 years, mean diabetes duration 9.81+/-5.9 years, contrast, low Lp(a) levels confer decreased risk of incident T2DM. This mean A1c values 7.9+/-2.1%. Mean CK-18 concentration was 397.75 U/L, study assesses the cardiometabolic phenotype and glucose homeostasis median 193 U/l. Mean concentrations of serum lipids were: triglycerides determinants of T2DM patients according to Lp(a) levels. 2.2+/-1.3, HDL-C 1.15+/-0.3, LDL-C 2.64+/-1.21 mmol/L. Mean liver enzymes 130 T2DM patients (mean (SD) age: 69 (9) years; diabetes duration 16 values were: alanine transaminase (Alt) 45.64 +/-43.88, asparagine (9) years) were divided in 2 groups according to plasma Lp(a): a low-Lp(a) transaminase (Ast) 35.83+/-34.35, gamma glutamyltranspeptidase (GGTP) group from the 1st Lp(a) quartile [QI] (n=32; mean 2.5 (0.5) mg/dL (median: 2.4 45.55+/-43.88 U/l. Serum CK-18 correlated signifi cantly and strongly with [perc. 25-75: 2.3-2.5] mg/dL), and a moderate-to-high Lp(a) group from the liver enzymes: Alt (r=0.65, p<0.000), Ast (r=0.59, p <0.000), GGTP (r=0.38, p remaining 3 quartiles [QII-IV] (n=98) with mean Lp(a) 27 (24) mg/dL (median <0.002) and bilirubin (r=0.37, p=0.006). Signifi cant, but weaker correlations 18 [10-36] mg/dL). Insulin sensitivity [S]; β-cell function [B]; residual β-cell between serum triglyceride, creatinine, uric acid and CK-18 concentration function adjusted for [S] (ie. the hyperbolic product [BxS]), and annual [BxS] were found (r=.0.35, p<0.004; r=0.46, p<0.000; r=0.43,p <43, p<0.001 loss rates were determined by HOMA. respectively). Serum CK-18 level did not correlate with glycemic control The 2 groups did not differ in gender; ethnicity; BMI; MetS; blood and other serum lipids. Serum triglycerides correlated also weakly but pressure; glucose-lowering and CV drugs; HbA1c; LDL-C or apoB. Low-Lp(a) signifi cantly with Ast and GGTP. The results of this study indicate, that in patients were older, by a mean of 5 years, but younger at diabetes diagnosis: patients with NAFLD serum CK-18 levels correlate, as expected, with liver

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A161 FOOT CARE—LOWER EXTREMITIES

enzymes and with triglyceride levels. These results suggest the potential 633A-P role of control of serum triglyceride in patients with type 2 diabetes in GLP-1 and Glucagon Receptors Dual Agonism Exerts Superior Lipid NAFLD prevention. Lowering Effects to GLP1R-selective Agonism in Obese Mice JULIE Z. LAO, ANNE-MARIE CUMISKEY, STEVEN STOUT, WENYU LI, EDWARD 632-P KOWALIK, DAPHNE SZETO, ANDREA NAWROCKI, LI-PING SUN, DAVID Adipocyte Specifi c SNAP23 Knockout Mice Are General Lipodystro- MCLAREN, BETH ANN MURPHY, ALESSANDRO POCAI, PAUL E. CARRINGTON, phy with Increased Cell Death Kenilworth, NJ, Rahway, NJ

POSTERS DAORONG FENG, JEFFREY PESSIN, Bronx, NY Glucagon-like peptide-1 receptor (GLP1R) and glucagon receptor (GCGR) dual Complications Human Lipodystrophy (LD) is typically associated with insulin resistance agonists are being developed by several pharmaceutical companies for the Acute and Chronic diabetes, hepatic steatosis and early cardiovascular diseases. SNAP23 is treatment of diabetes and obesity. Studies in mice and humans have highlighted a homologue of SNAP25 that was originally identifi ed as a component of a key role of glucagon on lipid metabolism. Here we report the lipid lowering the soluble N-ethylmaleimide sensitive factor attachment protein receptor effect of a dual agonist (DualAG, with EC50 of 0.54nM for mGLP1R and 0.21nM (SNARE) necessary for both in vivo and in vitro SNARE-dependent membrane for mGCGR) in diet-induced obese (DIO) mice and contrast the effects to the vesicle fusion. In adipocyte it is generously believed SNAP23 functions as a GLP1R selective agonist Liraglutide (Lira, with EC50 of 0.85nM for mGLP1R and component of the t-SNARE plasma membrane complex that is required for >100nM for mGCGR). We show that acute simultaneous activation of GLP1R the fusion of the v-SNARE containing GLUT4 vesicle. We generated adipocyte and GCGR in DIO mice leads to an increase in TG clearance and decrease in SNAP23-defi cient mice (Adip-SNAP23-/-) by crossing fl oxed SNAP23 mice with triglyceride (TG) assembly/synthesis as well as reductions in total cholesterol, adiponectin cre mice. Although we expected that the Adip-SNAP23-/- mice LDL and ApoB when compared to activating GLP1R alone. These changes would display impaired insulin-stimulated glucose uptake and GLUT4 plasma are accompanied by down-regulation of SREBP-1c and SREBP-2 and reduced circulating PCSK9 protein and gene expression with a corresponding increase membrane fusion, we surprisingly observed that these mice display a temporal in hepatic LDLR protein expression. The acute change in LDLR is not associated development of severe general lipodystrophy associated with adipose tissue with excess lipid accumulation in the liver. In conclusion GLP1R/GCGR dual infl ammation, lower energy expenditure, insulin resistance diabetes and liver agonists represent a new class of glucose and body weight-lowering agents steatosis. Characterization of the lipodystrophy by EchoMRI quantifi cation with PCSK9-lowering properties to be potentially used for the treatment of indicated that there was essentially no detectable fat mass by 24 weeks in the dyslipidemic diabetic patients at risk of coronary heart disease. Adip-SNAP23-/- mice although with relatively similar percentage of fat mass at 3 weeks old of age compared to WT mice. The progressive decrease of fat mass are associated with 4 to 20 fold increase of expression of F4/80, CD11c, FOOT CARE—LOWER EXTREMITIES TNFalpha, IL-6 and IL-1beta in both WAT and BAT. Quantifi cation of perilipin negative cell remnants indicated that nearly 50% of the epididymal adipocytes Guided Audio Tour: Step Up! Healing the Diabetic Foot (Posters: 634-P to of the SNAP23KO mice were dead at 4 weeks of age, approximately 70% of the 641-P), see page 15. subcutaneous adipocyte cells were dead at 1 week of age. Snap23 knock down has no effect on 3T3L1 fi broblasts but induced cell death after differentiation. & 634-P These data demonstrate that SNAP23 plays a critical role in the maintenance Comparison of Noninvasive Vascular Assessment Methods Detect- of normal adipocyte function and defi ciency of SNAP23 results in the induction ing Ischaemia in Patients with Diabetic Foot Ulcer of adipocyte cell death JARMILA JIRKOVSKA, JOHANA VENEROVA, SVATOPLUK SOLAR, LENKA VEDRALOVA, MIROSLAV ZAVORAL, Prague, Czech Republic 633-P Detection of peripheral arterial disease (PAD) using methods of non- Exome Sequence Analysis in a Multiethnic Type 2 Diabetes Case- invasive vascular assessment in patients with non-healing diabetic foot Control Study Identifi es Novel Putative Loss of Function Variants ulcer (DFU) is essential. The purpose was to compare individual methods Associated with the Lipid Profi le detecting ischaemia, verifi ed subsequently by angiography (AG). MANUEL A. RIVAS, XUELING SIM, HEATHER M. HIGHLAND, ANUBHA We included 32 consecutive patients with DFU and clinical suspicion of MAHAJAN, HAE K. IM, ADAM E. LOCKE, NIELS GRARUP, ANNA L. GLOYN, MARK PAD (mean age 68years, 75% males, 94% type 2 diabetes, mean duration MCCARTHY, MICHAEL BOEHNKE, JAMES B. MEIGS, CECILIA M. LINDGREN, of diabetes 16years, mean glycated hemoglobin 91mmol/mol, 53% active Oxford, United Kingdom, Singapore, Singapore, Houston, TX, Chicago, IL, Ann Arbor, smokers), treated at our foot clinic between 02/2010 and 08/2012, who MI, Copenhagen, Denmark, Boston, MA underwent several methods of non-invasive vascular assessment as well Dyslipidemia is a major risk factor for cardiovascular disease in individuals as following invasive AG. Criteria indicating ischaemia were defi ned as with and without type 2 diabetes (T2D). Hence, dissecting the role of absence of peripheral pulses; ankle brachial index (ABI) <0.9; total occlusion genetic variation to lipid trait variation is important for the management of or more than 50% stenosis (monophasic fl ow graph) of at least one of the dyslipidemia and to identifying novel drug targets. lower limb arteries for duplex ultrasonography (DUS) or as transcutaneous As part of the GoT2D and T2D-GENES sequencing projects, we analysed oxygen tension (TcPO2) ≤30 or ≤40mmHg treshold, respectively. exome sequence data from 12,940 individuals ascertained from multiple PAD was verifi ed by AG in 30/32 (94%) patients. Using the Graziani populations in fi ve major ancestry groups with approximately equal numbers Morphologic Classifi cation, 13% individuals were Class 1; 3% Class 2a; of T2D cases and controls informative for plasma lipid concentrations 7% Class 2b; 17% Class 3; 30% Class 4; 7% Class 5; 20% Class 6 and 3% (min.sample size 10,067 for high-density lipoprotein cholesterol [HDL-C], Class 7. We assumed PAD in 27/30 (90%) patients by absence of peripheral low-density lipoprotein cholesterol [LDL-C], total cholesterol [TC], and pulse palpation. 19/30 (63%) individuals had ABI<0.9, while 6/30 (20%) had triglycerides [TG]). inconclusive ABI>1.4. PAD was detected in 27/30 (90%) individuals by DUS, We specifi cally assessed the association of protein truncating variants in 28/30 (93%) by TcPO2≤30mmHg and in 29/30 (97%) by TcPO2≤40mmHg. (PTVs), with putative complete loss of function effect, on the phenotype We demonstrated high number of truly AG verifi ed PAD when suspected profi le using the multivariate rare variant and phenotype (MRP) test and by any of the noninvasive diagnostic methods. Absence of peripheral pulse univariate approaches including the SKAT test and the Bayesian similar palpation in patients with DFU should always lead to more detailed vascular effects model (SEM). status assessment. Concerning the individual methods, the results suggests Association analysis of PTVs and the joint occurrence of the lipid profi le that major amount of patients with DFU and PAD is identifi ed by TcPO2. Use identifi ed exome-wide signifi cant evidence of association (p< 2.5x10-6) of of TcPO2≤40mmHg as treshold for ischaemia in the management of early PTVs contributing to a dyslipidemia profi le (high TG, high TC, high LDL-C, revascularisation could be considered. -8 Supported By: MO0901-8-8140 low HDL-C) at LPL (PMRP = 9.1x10 ). In addition, we found rare (MAF < 0.5%) PTVs associated with a favorable lipid profi le (low TG, low TC, low LDL-C, -7 & 635-P high HDL-C) at APOC3, PCSK9, and APOB (max PMRP = 2.1x10 ). We further examined the association of PTVs in 18 genes previously identifi ed to contain Allogeneic Transplantation with the Concomitant Use of Adipose- causal mutations for lipid disorders. Eight of these genes had suggestive Derived-Stem-Cell (ADSC) Sheets and Artifi cial Dermis Accelerated evidence of association (Bayes Factor [BF] > 10) for one of the four lipid the Wound Healing of Rat Diabetic Ulcers traits (p < 10-6). In conclusion, we have identifi ed key novel complete loss of YUKA KATO, TAKANORI IWATA, KAORU WASHIO, TOSHIYUKI YOSHIDA, KAZUKI function alleles associated with the joint occurrence of the lipid profi le that IKURA, MASAYUKI YAMATO, TERUO OKANO, YASUKO UCHIGATA, Tokyo, Japan may guide therapy of dyslipidemia in individuals with type 2 diabetes. Diabetic ulcer is one of the major complications in diabetic patients. Currently being used for treating ulcers with full-thickness skin defects in Supported By: ADA (7-12-MN-02) diabetic patients, artifi cial dermis is unable to cure the ulcers completely.

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A162 FOOT CARE—LOWER EXTREMITIES

Adipose-derived-stem-cells (ADSCs) possessing an angiogenic property shoe intervention (1/1/2010 thru 12/31/2012). The index date was defi ned as have been transplanted to wounded skin. However, the poor retention rate the fi rst observed claim for therapeutic footwear (HCPCS A5500), or custom of transplanted ADSCs on the wound site, limits the therapeutic effect molded shoes (HCPCS A5501), and customized inserts/orthoses (HCPCS A5512 accordingly. To resolve this problem, this study used cell sheet technology or A5513). Each patient was required to have at least one inpatient or non- and evaluated the effi cacy of ADSC sheets in full-thickness skin-defects in diagnostic outpatient medical claim with a T2DM diagnosis (ICD-9-CM 250.x0 diabetic rats. and 250.x2) during the 1-year period before therapeutic shoes and be >18 years Rat ADSCs (rADSCs) were collected from the inguinal fat of normal rats of age. We identifi ed a large group of patients who fulfi lled these criterion and seeded onto temperature-responsive culture dishes at passage 3 for (n=32,975). Mean age (69.3+11.1), gender (55.3% male) and common comorbid POSTERS fabricating cell sheets. rADSCs exhibited a colony forming, adipogenic, conditions of the study population including cardiovascular conditions, Complications and osteogenic differentiation abilities in vitro, suggesting that rADSCs hypertension, and kidney disease were comparable to other database studies. Acute and Chronic possessed mesenchymal stromal cell-like properties. After 1-year, the proportion of T2DM patients using therapeutic footwear and Full-thickness skin defects were created in the parietal region of diabetic having foot ulceration decreased by 30% (12.4% to 8.7%), polyneuropathy rats, and periostea were removed. The defects were covered with or without decreased by 36% (5.3% to 3.4%), and amputations of the lower limb by 12% rADSC sheets, which were sutured with artifi cial dermises. At 2 weeks after (2.5% to 2.2%). This study suggests that therapeutic shoes may have an impact transplantation, rats were sacrifi ced, and the wound regions including the on subsequent foot ulcers and amputations in T2DM patients. Further study is calvariae were excised and histologically investigated. needed to fully clarify the potential effect of therapeutic shoes. The averaged blood vessel density was approximately 7-fold signifi cantly higher in the transplanted group compared to the control group (p < 0.05). & 638-P And, in the transplanted group, the wound areas at 2 weeks were signifi cantly Factors Affecting Length of Hospital Stay and Mortality in Patients smaller than those of the control group (p < 0.05). with Infected Diabetic Foot Ulcer Requiring Surgical Drainage In conclusion, the transplantation of allogeneic rADSC sheets with YOUNG-KYUN LEE, YOU JIN LEE, KYOUNG MIN LEE, Seongnam, Republic of artifi cial dermis accelerated neovascularization and wound closure in full- Korea, Goyang-si, Republic of Korea, Bundang-gu, Republic of Korea thickness skin defects in diabetic rats, indicating that rADSC sheets might This study aimed to investigate the factors affecting length of hospital be useful for treating the skin wound of diabetic patients. stay and mortality in patients with infected diabetic foot ulcer requiring surgical drainage. & 636-P Data on length of hospital stay, mortality, demographics, and other medical History of Lower Extremity Amputation and Risk of Cardio-Renal information were collected retrospectively from 79 patients (60 men, 19 women; Events and Mortality in Subjects with Type 1 Diabetes mean age, 66.1 [SD, 12.3] years) with infected diabetic foot ulcer that underwent KAMEL MOHAMMEDI, LOUIS POTIER, SAMY HADJADJ, RONAN ROUSSEL, surgical drainage. Multiple linear regression analysis was performed to analyze MICHEL MARRE, GILBERTO VELHO, Paris, France, Poitiers, France the factors determining length of hospital stay, and multiple Cox regression Aim: Lower Extremity Amputation (LEA) is a severe diabetic complication. analysis was fi tted to assess the factors contributing to mortality. There are limited data regarding cardio-renal outcomes related to LEA in Erythrocyte sedimentation rate (ESR, P = 0.034), glycosylated hemoglobin type 1 diabetic patients. We evaluated the risk of cardiovascular and renal (HbA1c, P = 0.021), body mass index (BMI, P = 0.001), and major vascular events and mortality in type 1 diabetic subjects with LEA. disease (cerebrovascular accident or coronary artery disease; P = 0.004) were Methods: We studied the association of LEA with the incidence of end signifi cant factors determining length of hospital stay, whereas severity of stage renal disease (ESRD), myocardial infarction (MI), stroke, cardiovascular diabetic foot ulcer (P = 0.007) and serum creatinine level (P = 0.018) were and all-cause mortality in type 1 diabetic participants during the follow-up of signifi cant factors contributing to mortality. GENEDIAB (from 1994 to 2006) and GENESIS (1999 - 2007) cohorts (n=806, Length of hospital stay was affected by the severity of infl ammation age 44±12 years, male gender 55%, duration of diabetes 28±9 years, HbA1c (ESR), recent blood glucose level (HbA1C), BMI, and major vascular disease. 8.6±1.5%, duration of follow-up 6±3 years). Cox proportional hazard analyze The mortality of patients was affected by the severity of diabetic foot ulcer was used to estimate hazard ratio (HR) adjusted for sex, age, cohort (Model and the status of renal function (Cr). This study provides physicians with 1) and for Model 1 plus smoking, duration of diabetes, BMI, HbA1c, urinary useful information on the prognosis of patients with infected diabetic foot albumin excretion, eGFR, hypertension and lipids lowering therapies at ulcer undergoing surgical drainage. baseline (Model 2). Results: At baseline, 63 (7.8%) participants had LEA (major and minor & 639-P combined). The incidence of ESRD (n = 55), MI (n = 50), stroke (n = 26), Osteomyelitis Negatively Impacts Outcomes of Patients with Diabetic cardiovascular death (n = 30) and all-cause mortality (n = 73) was 1.2 Foot Infections (0.9 - 1.5), 1.0 (0.7 - 1.3), 0.5 (0.3 - 0.7), 0.6 (0.4 - 0.8) and 1.4 (1.1 - 1.7) per KIMBERLEE B. HOBIZAL, DANE K. WUKICH, Pittsburgh, PA 100 person-years (95% CI) respectively. In Model 1, history of LEA was Diabetic foot infections (DFI) are limb threatening and often associated associated with the incidence of ESRD (HR 1.61, 95% CI 1.00 - 2.42, p = with osteomyelitis (OM). The aim of this study was to assess the outcomes 0.05), MI (HR 2.15, 95% CI 1.62 - 2.84, p < 0.0001), cardiovascular death (HR of patients hospitalized with DFI and OM. Our hypothesis is that OM is 2.05, 95% CI 1.32 - 3.12, p = 0.002) and all-cause mortality (HR 2.08, 95% CI associated with higher rates of adverse outcomes. 134 patients hospitalized 1.57 - 2.74, p < 0.0001). In Model 2, LEA was again associated with ESRD with DFI were reviewed, identifying 86 patients (65%) with culture proven (HR 1.87, 95% CI 1.04 - 3.11, p = 0.03), MI (HR 1.90, 95% CI 1.27 - 2.79, p = OM and 47 patients (35%) with soft tissue infection alone. Radiographs were 0.002), cardiovascular death (HR 2.14, 95% CI 1.27 - 3.54, p = 0.005) and all- obtained in all patients and advanced imaging was utilized in selected cases. cause mortality (HR 1.84, 95% CI 1.35 - 2.49, p = 0.0002). No association was The two patient groups were similar with regard to age and gender. OM observed with stroke in both models. was associated with longer hospital stays and higher rates of amputation Conclusion: A history of LEA was associated with increased risk of ESRD, but did not signifi cantly impact the IDSA classifi cation of infection severity. MI, cardiovascular and all-cause mortality in type 1 diabetic patients. The rate of minor and major amputation in patients with OM was 43% and 18% respectively, while the rate of minor and major amputation in soft & 637-P tissue infections was 22% and 6% respectively. Traditional serum markers Characteristics and Health Care Resource Utilization of Type 2 of infl ammation (WBC, ESR and CRP) were not signifi cantly different when Diabetes Mellitus (T2DM) Patients Using Therapeutic Footwear comparing those patients with and without OM. In patients with confi rmed MICHAEL E. MINSHALL, EMILY DURDEN, DANIEL M. HUSE, DONNA MCMORROW, OM, 37% had an ESR < 70, 45% presented with a normal WBC and only 29% ROY H. LIDTKE, Vista, CA, Ann Arbor, MI, Chicago, IL of patients had fever > 38 degrees. Consequently, we recommend that the The prevention of foot ulcers in patients with diabetes is critical in reducing diagnosis of OM in hospitalized patients be confi rmed with bone culture and/ lower extremity amputations as improperly fi tting footwear has been or histopathology rather than relying on serum markers of infl ammation. implicated as an important cause of foot ulceration. Therapeutic footwear, including depth shoes, custom molded shoes, and inserts, may prevent or reduce ulceration by relieving areas of excess pressure, reducing shock and shear, and accommodating foot deformities. The purpose of this study was to describe the demographic, clinical, and complication profi le for T2DM patients wearing therapeutic footwear in commercially insured and Medicare T2DM patients over a 2-year period: 1-year before and 1-year following therapeutic

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A163 FOOT CARE—LOWER EXTREMITIES

foot ulcer (HR 3.63, 95% CI 1.98-6.66) or amputation (4.61, 2.34-9.09), insulin use (2.36, 1.16-4.80), MI (3.57, 1.81-7.04), AAI (0.26, 0.01-0.67), TcPO2 (0.98, 0.96-1.00), and HbA1c (1.09, 1.00-1.18), but no associations were seen with age, weight, sex, creatinine, or diabetes duration. Using a forward selection algorithm among males only, the following covariates signifi cantly predicted amputation in a multivariable model: history of foot ulcer (2.78, 1.51-5.12) and amputation (3.87, 1.88-7.96), MI 2.41 (1.13-5.11), AAI (0.32, 0.11-0.92), TcPO2 (0.98, 0.96-1.00), HbA1c (1.10, 1.01-1.21), and creatinine (1.07, 1.00-1.14). Harrell’s C concordance statistic POSTERS

Complications for this model (equivalent to area under the ROC curve) was 0.902, indicating

Acute and Chronic excellent discrimination. We conclude that multiple factors contribute to the causation of diabetic foot ulcer, including arterial disease, tissue oxygenation, neuropathy, diabetes control, and renal disease, and that these factors permit highly accurate amputation prediction. Supported By: U.S. Dept. of Veterans Affairs & 640-P Effectiveness Targets for Diabetic Foot Ulcer Prevention Efforts 642-P NEAL R. BARSHES, SAMIRA SAEDI, JAMES WROBEL, LECHAUNCY WOODARD, Joint Mobility as Practical Evaluation Scale of Foot Ulcerative Risk PANOS KOUGIAS, DAVID G. ARMSTRONG, Houston, TX, Ann Arbor, MI, Tucson, AZ PIERGIORGIO FRANCIA, MASSIMO GULISANO, ALESSANDRA DE BELLIS, ANNA Introduction: Sustained efforts at diabetic foot ulcer (DFU) and limb loss TEDESCHI, ROBERTO ANICHINI, Florence, Italy, Pistoia, Italy prevention are infrequent in most health care systems despite high costs Determine how ankle joint mobility (AJM) evaluation may be useful in associated with such complications. We sought to estimate effectiveness monitoring and predicting the risk of foot ulcer in diabetic patients. targets at which cost-savings (i.e. improved health outcomes at decreased In 2006 we evaluated AJM by inclinometer in: 85 diabetic patients and 44 total costs) might occur. healthy control subjects. Methods: A Markov model with probabilistic sensitivity analyses was used Diabetic patients were followed from diagnosis of foot ulcer and after 7 years to simulate 5-yr. survival, diabetes-related foot complications, and costs. the group was subdivided in: 49 adults (group DNU) mean age±SD 59,19±10,11 Clinical event and cost estimates were obtained from previously published years, and 14 young (group YD) mean age 13,63±1,24 years without history of trials and studies. A diabetic population without previous DFU but with 17% foot ulcer; 14 patients with history of foot ulcer detected before evaluation neuropathy prevalence and 11% peripheral arterial disease (PAD) prevalence (group DUB) mean age 65,5±8,28 years, 8 patients with history of fi rst ulceration was assumed. Primary prevention (PP) was defi ned as reducing initial DFU detected by the 7th year of evaluation (group DUA) mean age 65,25±10,11 years. incidence and secondary prevention (SP) as increasing the probability of The control subjects were subdivided in: 30 adults controls mean age 58,42±5,97 receiving timely, adequate treatment for a DFU. years, and (group CA) 14 young controls (group CY), mean age 14,43±1,79 years. Results: PP was >90% likely to provide cost-savings when annual The AJM in plantar and dorsal fl exion of different groups was: group CY prevention costs are <$50/person and/or annual DFU incidence is reduced 152.89°±13.17°, group CA 133,72°±18,43°, group YD 119,46°±13,92°, group by >25% (see Figure). PP provided cost-savings at much lower effectiveness DNU 109,26°±27,98°, group D 101,94°±27,62°, group DUA 94,45°±8,98°, group targets when focused on patients with neuropathy and/or PAD . SP reduced DUB 80,60°±21,15°. AJM was signifi cantly higher in the group CY compared limb loss rates but did not provide cost-savings in any scenario studied. to the other groups (p<0,005). Group CA showed an AJM signifi cantly higher Conclusions: Low-cost DFU PP efforts producing modest decreases in DFU than the groups of adults with diabetes: DNU, DUB, DUA (p<0,001) and the incidence may be the most likely opportunity for cost-savings, esp. if focused group of young diabetic patients: group YD (p<0,05). Group YD showed a on patients with neuropathy and/or PAD. not signifi cantly difference of AJM compared to the group DNU but it was signifi cantly higher than group DUB and DUA ( p<0,001). AJM value was signifi cantly lower in patients with a history of one or more ulcers detected before evaluation (group DUB) compared to all the other groups (p<0,001) with the exception of the group DUA. Within the 22 diabetic patients of the groups DUA and DUB, in 17 cases (77,27%) the fi rst ulceration was detected in the same foot presenting lower ankle joint mobility. The level of AJM follows foot health condition. It allows to obtain a valid and reliable ulcerative risk scale reporting an high risk zone, indicating also the foot at higher ulcerative risk.

643-P WITHDRAWN

& 641-P A Prospective Study of Risk Factors for Lower Limb Amputation EDWARD J. BOYKO, JESSIE H. AHRONI, AMBER SEELIG, Seattle, WA Little prospective research has been conducted on the risk of diabetic lower limb amputation with limb-specifi c neurovascular measurements. We prospectively followed 1,641 diabetic veteran primary care patients without foot ulcer for the occurrence of an lower limb amputation. Each lower limb underwent the following tests: ankle-arm index (AAI), 5.07 monofi lament insensitivity (MI), and transcutaneous oximetry of the dorsal foot at 44o C (TcPO2). Multiple other characteristics were assessed including diabetes features, body size, past history of ulcer and amputation on either foot, and serum creatinine concentration. Cox regression was used to estimate hazard ratios (HR) for amputation in one limb from each patient by exposures of interest. Baseline characteristics were 98% male and mean age 64 yrs, weight 97 kg, and diabetes duration 17 yrs. Mean follow-up duration was 4 yrs, during which time 50 amputations occurred. In univariate Cox models, signifi cant predictors of amputation were history of

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A164 FOOT CARE—LOWER EXTREMITIES

646-P Limb Salvage with Transmetatarsal Amputations (TMA) at the Carl T. Hayden VA Medical Center: A Retrospective Review of 59 Patients ROBERT FRYKBERG, DEVIN BLAND, EDWARD TIERNEY, JAMINELLI L. BANKS, Phoenix, AZ The surgeon is confronted with much controversy when discussing

644-P the Transmetatarsal amputation (TMA) in the diabetic population during POSTERS Inhibition of Prostaglandin Transporter (PGT) Accelerates Wound perioperative planning. There have been relatively few studies analyzing Complications Healing in Diabetic Rats by Promoting Perfusion and Vasculariza- the outcomes when comparing various risk factors during the perioperative Acute and Chronic tion period. A study comparing the risk factors associated with the potential YULING CHI, ZHONGBO LIU, MAHRUKH SYEDA, RAIHAN MIRZA, Bronx, NY candidate would prove to be very useful to the operating surgeon. One of the main causes of impaired wound healing in diabetes is dysvascular Fifty-nine patients who had undergone TMA procedure at Carl T. Hayden condition presented as peripheral ischemia resulted from diminished arterial VAMC from 2006-2013 were included in this retrospective analysis. Risk factors including smoking, PAD <0.7 ABI, CKD, presence of infection, HbA1C, blood fl ow and defective local vascularization. Prostaglandins including PGE2 elevated fi brinogen and homocysteine were recorded as well as healing and PGI2 are vasodilators, maintaining balanced vascular pressure, patency and perfusion to ensure adequate blood fl ow to peripheral tissues. They rates, time to heal, post operative complications (dehiscence, infection, also stimulate angiogenesis by inducing vascular endothelial growth factor. more proximal amputation, additional surgery). Catabolism/degradation of PGs is mediated by the prostaglandin transporter Average age of patients was 63.4 years, all were male. Diabetes was (PGT). We have shown that PGT is induced by hyperglycemia and wounding, present in 81% (48/59) of this population. Overall healing rate was 66% contributing to weaken PG signaling in diabetic wound healing. PGT inhibition (39/59). Out of the 39 patients that healed 79% healed at the TMA level. There raises intact PG levels. Thus we hypothesized that systemic and or local was a 30% (18/59) infection rate in the patients during the post operative PGT inhibition by our recently developed PGT inhibitor, T26A, would mitigate period. Overall, 42 patients developed postoperative complications, diabetes peripheral ischemia by potentiating vasodilation, increasing blood fl ow and being present in 81% (34/42). 27% (16/59) had PAD, with 44% requiring a stimulating vascularization. We created hindlimb ischemia in streptozotocin more proximal amputation (P=0.05). In our patient population the mean WBC induced diabetic and non-diabetic Sprague Dawley rats and measured blood was 12.3. 44% (26/59) of patients had WBC>12.0 with 30% (18/59) requiring fl ow using a Laser Doppler. Diabetic rats exhibited signifi cantly reduced blood a more proximal amputation (P=0.03). fl ow as compared to non-diabetic rats. Systemic administration of T26A via This study demonstrates that elevated WBC >12 predicted the need for jugular vein increased blood fl ow in non-diabetic rats and caused more than more proximal amputations. Similarly, the presence of PAD (ABI<0.7) also appear to be associated with the need for further amputation. In our study 60% recovery in diabetic rat blood fl ow. Moreover T26A prolonged PGE2 population CKD, smokers, elevated fi brinogen levels and HbA1C>8.0 did effects, indicating that T26A was able to slow PGE2 degradation. In separate sets of experiments, we created cutaneous wounds on rat dorsa and applied not seem to increase the likelihood of postoperative complications as one vehicle or T26A. Topical T26A increased vessel formation at wound sites would expect. It is important to understand risk factors that can contribute and corrected defective vascularization in diabetic wounds, resulting in to successful outcomes in limb salvage. accelerated wound healing. Combination of systemic and local administrations of T26A exhibited additive benefi cial effects in promotion of wound healing. 647-P These results indicate that PGT modulates arterial blood fl ow, mobilization of Link between Depression and Diabetic Foot Ulcers progenitor cells and angiogenesis, important players in wound healing. CECIL THOMAS, G. GILL, J. THOMAS, E. NADERALI, Liverpool, United Kingdom Supported By: ADA (1-11-JF-06); AHA (0735066N) Foot problems are the commonest cause of hospital admissions amongst diabetic patients in the UK. The aim of this case control study was to evaluate 645-P the impact of foot ulcer in diabetic patients. The study comprises diabetic Role of Kinins in Wound Healing in Diabetes patients with foot ulceration (n=50; case control), and matched diabetic DORINNE DESPOSITO, CATHERINE CHOLLET, CHRISTOPHER TAVEAU, RONAN patients without foot ulceration (n=50; controls).A Hospital anxiety and ROUSSEL, FRANCOIS ALHENC-GELAS, NADINE BOUBY, LUDOVIC WAECKEL, depression scale (HAD scale) questionnaire was used to measure the link Paris, France between diabetic foot ulcers and anxiety and depression status. The HAD scale The diabetic foot, a leading cause of hospital admissions in the developed world, consists of a 14 item questionnaire comprising two subscales of seven items is associated with pain, decrease in patient’s quality of life, considerable costs, each for anxiety and depression. There was a signifi cant (p=0.035) differences and amputation. In this study, we determined the role of KKS, via activation of in HAD scale scored mean (±SD) between two groups (cases: 15.12± 9.48) bradykinin receptors (B1R or B2R), in a mouse model of diabetic wound healing. vs. controls: 11.46±7.48). Interestingly, when anxiety and depression scores Diabetic or nondiabetic mice were wounded with an 8-mm punch biopsy were scored separately, there was a signifi cant difference in depression but and then are treated or not with specifi c B1R or B2R agonists (720nmol/kg.d-1) not the anxiety scores between the two groups. The anxiety scores for cases and/or B2R antagonist (Icatibant, 500µg/kg.d-1). The wound-healing surface mean (±SD) were 7.86±5.34 whilst that was controls were 6.34±4.37 with the was daily followed-up. At 11 days, the scars were analyzed by histology P value=0.123 indicating no signifi cant differences while depression scores for (Masson’s trichrome staining) and B1R and B2R expression was assessed cases were 7.46±4.63 vs. controls 5.14±3.65 with a P value=0.007 indicating (RT-qPCR). Effects of the agonists on cells (fi broblasts and keratinocytes) a signifi cant differences between two groups Therefore, this study indicates migration and proliferation were also analyzed in vitro. that foot ulcer patients showed signifi cantly higher HAD (P<0.05) with In diabetic condition, mRNA of B1R and B2R was increased in skin (p<0.01). depression but not the anxiety, being the major contributing factor to higher B1R activation had no effect on wound closure in our model. In contrast, HAD scales. However, we are unable to elucidate if depression is the result of B2R activation dramatically delayed wound healing in diabetic (p<0.001) or foot ulceration or the foot ulceration is the consequence of depression leading nondiabetic (p<0.01) mice. Histological analysis of scars showed signifi cant to lack of self-care. This hypothesis requires further investigation.The study skin disorganization and epidermis thickening with B2R agonist (p<0.05). In suggests that in diabetic patients with foot ulceration, depression, and anxiety vitro, B2R agonist induced an increase of keratinocyte proliferation (+46% to a much lesser anxiety, plays a pivotal role in their psychological well-being. after 48h, p<0.01) and a stimulation of keratinocyte migration (+30% after These fi ndings have implications for the evaluation, planning and management 24h, p<0.05). These effects were associated with ERK phosphorylation, of patient care in diabetic foot disease. occuring downstream of EGFR activation (p<0.05). B2R agonist had no effect on fi broblast migration but decreased fi broblast proliferation (-33% after 48h, 648-P p<0.05). Co-treatment with Icatibant abrogated in vivo and in vitro effects Establishing Clinically Meaningful and Comparable KPI’s for observed with B2R agonist. Moreover, Icatibant alone hastened wound Diabetes Foot Care Services healing and decreased the epidermis thickening induced by diabetes. THYRA BOLTON, VANESSA NUBE, DANIELLE VELDHOEN, LYNDA MOLYNEAUX, In conclusion, KKS, through the B2R but not the B1R, plays a critical role MARIA I. CONSTANTINO, MARGARET MCGILL, TED WU, STEPHEN M. TWIGG, in proliferation and remodelling phases of skin wound healing in mice. While Sydney, Australia, Camperdown, Australia more studies are needed, Icatibant could be used to correct the diabetic A lack of standardised reporting in diabetic foot disease outcomes limits wound healing defect. benchmarking of services. This study aimed to develop clinically meaningful Supported By: Société Francophone du Diabète service key performance indicators (KPI’s) by retrospectively examining

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A165 FOOT CARE—LOWER EXTREMITIES

systematic data collected in our High Risk Foot Service. A 4 year interval 650-P audit of patients with diabetic foot ulcers (DFU) with 2 yrs follow-up was Removable Walker Is as Safe and Effective as Total Contact Cast undertaken: 492 pts with 1564 DFU attended with a mean 3.2 DFU/pt. (TCC) and Irremovable Walker in Healing Neuropathic Diabetic Foot Mean age was 65.4±13.3 yrs, diabetes duration 15.5 (range 9.1-22.6) yrs, Ulceration (DFU) 72% were male and 55% anglo-celtic; at follow-up 13% of pts had died, and ALBERTO PIAGGESI, SILVIA MACCHIARINI, CHIARA MATTALIANO, GIACOMO 15% were referred elsewhere. Ulcer severity by Texan Grading showed 34% CLERICI, FABIO ROMAGNOLI, CRISTIANA VERMIGLI, FABRIZIA TOSCANELLA, were infected, 13% ischemic, and 20% both infected and ischemic. Most ELISABETTA IACOPI, Pisa, Italy, Milan, Italy, Ancona, Italy, Perugia, Italy, Rome, were superfi cial (71%), 9% to tendon and 6% to bone. Time to presentation

POSTERS Italy

Complications was 0.4 (0.1-1) months with new pts delayed to 1.0 (0.5-2.1) months. Ulcer To check if the same device was safe and effective both in the removable Acute and Chronic healing was 86% with a median 1.7 (0.8-3.6) months. The other 14% required and irremovable form to offl oad DFU compared to TCC, we studied 58 amputation, mainly minor. Re-ulceration (any location) was 66%, and 34% Type 2 diabetic patients (M/F: 37/21; age: 66±13 yrs; diabetes duration: pts had more than 1 DFU averaging 4.3 past DFU. Based on these data, 18±12 yrs; BMI: 29.7±4.9 Kgm2; HbA1c 8.0±0.9%) with plantar neuropathic Fig. 1 indicates our proposed minimal dataset of Primary and Secondary ulceration graded IA and IIA according to Texas University Scoring System KPIs. These KPIs include items linked to healing and re-ulceration and to (TUSS), from fi ve diabetic foot clinics in Italy. Patients were randomised into local service factors, they are comprehensive and compare favorably with three different groups: Group A [N. 19; HbA1c 7.9%, area of the lesion (AL) available published data. We recommend the KPIs be considered in reporting 2.1±1.4 cm2], offl oaded with TCC; Group B (N. 19; HbA1c 8.1%, AL 2.2±0.9 to aid benchmarking in diabetes foot care services. cm2), which was offl oaded with a irremovable walker (Optima Diab walker, Molliter, Civitanova Marche, I), and Group C [N. 20; HbA1c 8.0%, AL 2.4±1.7 cm2], which was offl oaded with the same device, removable. Healing time of DFUs, adverse events and patient’s compliance were evaluated in a six- month follow up. Healing time did not differ signifi cantly between the groups, being 24.40±12.94 days in Group A, 27.58±18.48 days in Group B and 32.67±8.04 days in group C. Adverse events occurred in 4 patients of group A, 1 patient in Group B and 2 patients in Group C, showing again no difference between the three groups. Patients’ compliance in Group C was higher (p<0.05) than in Group A and B, since no patient in Group C retired the consent to participate 649-P during the follow up, vs. 2 patients in group B and 5 in group A. Topical Application of ORB1+ Human Mesenchymal Stem Cells Removable Optima diab offl oading device was as safe and effective, but Seeded in Excellagen™ Scaffold Augments Wound Healing in a better tolerated, in the treatment of neuropathic DFU than the same device Diabetic Wound Model rendered irremovable and TCC. SWAPNIL B. PATIL, XIZHE CHEN, LUKE WATSON, PAUL LOFTUS, LISA O’ FLYNN, LOIS A. CHANDLER, GABOR M. RUBANYI, STEPHEN J. ELLIMAN, TIMOTHY 651-P O’BRIEN, Galway, Ireland, San Diego, CA Infl ammation Regulates Plasma Concentrations of MicroRNAs in Non-healing foot ulcers are a major complication in diabetic patients. Type 2 Diabetes Associated Impaired Wound Healing Many of these patients require amputation and there is thus an urgent need SEEMA DANGWAL, BERND STRATMANN, CHRISTINE FALK, THOMAS THUM, to develop new therapies to treat such ulcers. Mesenchymal stem cells DIETHELM TSCHÖPE, Hannover, Germany, Bad Oeynhausen, Germany (MSCs) are known to promote angiogenesis with improved wound healing. MicroRNAs (miRNAs/miRs) are highly conserved master regulators of Biomaterials may increase viability of cells and thus enhance therapeutic gene expression. MiRNAs circulate in blood in a remarkably stable form and effi cacy. Orbsen has identifi ed a novel antibody (ORB1) which can be used exert cellular effect upon cellular uptake. to prospectively FACS-isolate ORB1+CD45- MSC from human bone marrow We investigated the infl uence of infl ammation on the plasma miRNA with enhanced MSC/MNC purity ratios of up to 1/4. signature of type 2 diabetes patients with impaired wound healing. In this study, 1 million of ORB1+, ORB1- and Plastic Adherent (PA) human Sixty-one type-2 diabetes patients were grouped according to concomitant MSCs were seeded in Excellagen matrix and applied to a cutaneous wound peripheral arterial disease (PAD) and chronic wounds (W). Plasma miRNA in an alloxan-induced diabetic rabbit ear ulcer for period of 1 week. When profi les of diabetic controls (DC) were compared to patients with PAD+W compared to the untreated group, the ORB1+ cells in Excellagen showed the and validated in all patients i.e. DC (n=23), D+PAD+W (n=27), D+PAD (n=11) greatest degree of wound healing as assessed by statistically signifi cant vs. 20 healthy controls using qRT-PCR. increases in percentage wound closure and increased angiogenesis. ORB1+ Differential plasma concentrations of 41 miRNAs were detected. Among cells signifi cantly augment the wound healing potential of Excellagen™ alone, these, MiR-191, miR-126 and miR-200b concentrations were signifi cantly which also exhibited increased healing responses compared to untreated decreased in diabetic subjects vs. healthy controls (p<0.0005) but reverted controls. Hence, with improved wound healing potential and augmenting in presence of PAD+W. angiogenesis, these specifi cally selected and defi ned ORB1+ MSC seeded in Higher circulating C-reactive protein and cytokine levels were observed in an Excellagen™ matrix may lead to a new therapeutic product to treat non- patients with PAD+W compared to DC (p<0.05). A signifi cant correlation of healing diabetic foot ulcers. miR-191 and miR-200b with circulating C-reactive protein levels (r=0.333 and 0.329 respectively) was observed among diabetic patients. To mimic clinical fi ndings in vitro, the release of all three miRNAs in culture-supernatants was measured upon LPS or cytokine stimulation of vascular endothelial cells which was found to be increased. Furthermore the transient overexpression of miR-191 or miR-200b in glucose treated human dermal fi broblasts suppressed their proliferation, whereas miR-200b overexpression in diabetic human dermal micro-vascular endothelial cells signifi cantly inhibited the tube formation. Our study reports for the fi rst time that plasma levels of circulating miRNAs in type-2 diabetes patients with chronic wounds and PAD are infl uenced by underlying infl ammation, which might control cellular homeostasis during diabetic wound healing.

Supported By: European Regional Development Fund (305736 (REDDSTAR)

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A166 FOOT CARE—LOWER EXTREMITIES

652-P femoropopliteal bypass). Complete healing occurred in 92% of patients alive Utilization Rates of Various Offl oading Modalities for Charcot Foot at 2 years. Mortality was 7.6%. in a Large Managed Care Network Major amputation and mortality were low in this group of high risk JAMES WROBEL, NIDHI TALWAR, KEIKO ASAO, JOSHUA STEIN, Ann Arbor, MI patients with established osteomyelitis at presentation despite a surgically The objective was to describe offl oading approaches used in practice for conservative approach. Based on this study we believe that the treatment of Charcot foot (CN) in a large managed care network. (a) MRI scans are not routinely indicated to diagnose osteomyelitis. The Clinformatics DataMart database (OptumInsight, Eden Prairie, MN) (b) Angiography is not required in the majority of patients but is required in all patients where amputation is being considered. contains detailed records of all benefi ciaries in a managed care network POSTERS across the United States. The dataset contains demographics, socioeconomic (c) Major amputation decisions should be clinically rather than angio- Complications status, medical claims, laboratory data, and outpatient pharmacy claims for graphically based. Acute and Chronic all benefi ciaries receiving care from 2001 through 2011. (d) Many patients can be managed on an out patient basis. In patients with diabetes, we identifi ed 8,785 individuals carrying ≥1 (e) The diabetic foot MDT can be led by a Diabetologist with a keen Charcot foot diagnosis (CN) (ICD-9-CM 713.5x) during 2001-11. In the CN interest in the diabetic foot. group, 4,947 (56%) received offl oading treatment other than custom or orthopedic shoes. In the treated group, the most recommended treatment 654-P total contact casts were applied in only 604 (12.2%) of patients. Removable Smartsox: An Optical Fiber-based Smart Textile to Prevent Diabetic cast walking boots were used in 2,337 (47.2%) of patients and Charcot Foot Amputation Restraint Orthotic Walker (CROW) was used in 2,006 (40.5%) patients. The BIJAN NAJAFI, GURTEJ GREWAL, SAMAN PARVANEH, ROBERT A. MENZIES, Venn diagram (Figure 1) shows 210 unique patients (4.2%) treated with total TALAL TALAL, DAVID ARMSTRONG, Tucson, AZ, Doha, Qatar contact casts exclusively. Prevention of diabetic foot ulcers through identifi cation of stress-induced Total contact casts are considered the gold standard for treating CN. We infl ammation has been shown to be a potentially effective strategy. There found very low utilization rates (4.2-12.2%) of total contact cast treatment. have been signifi c ant recent ad vances in measurement of plant ar temper ature Our fi ndings are consistent with others describing very low utilization of and stress but there exists a paucity of data in simultaneous measurement of total contact casts for treating diabetes-related foot ulcers. these parameters and their contribution to risk prediction models for diabetic foot ulceration (DFU). We propose a novel technology to quantify early tissue injury prior to clinical expression at the skin-level, leading to an ulcer. The proposed technology utilizes wearable garment (SmartSox) providing real time measures of plantar pressure, temperature and joint motion, which are of key importance for assessing foot at risk. The current study validated the accuracy of SmartSox in 21 people at high risk for DFU. Multiple sensors were juxtaposed on the length of an optical fi ber integrated in a comfortable sock (Novinoor LLC, IL). Changes in temperature and pressure under anatomical regions of the heel, midfoot, 1st and 5th metatarsal heads, and big toe were measured based on changes in wavelength of light. The prototype was tested during 200 steps in prescribed footwear. For validation images were taken with a thermal camera (at baseline after fi ve-minute temperature acclimation and after walking) and plantar pressure was measured using the F-scan system (TekScan®Inc) during walking. All the 21 recruited patients perceived the device as comfortable. A signifi cant correlation was observed between both pressure and temperature measured by SmartSox and reference systems under different anatomical regions of interest (r>0.6, p<0.05). This study demonstrates that SmartSox is feasible for safe in-shoe measurements of temperature and pressure during walking. The proposed technique empowers clinicians and patients to conduct quick objective assessments of areas at high risk for ulceration, infection, and amputation. Supported By: Qatar National Research Fund (NPRP 4-1026-3-277)

655-P Supported By: NIH WITHDRAWN 653-P A Diabetologist Led, Surgically Conservative Diabetic Foot Service Is Associated with Low Amputation Rates and Low Mortality in Patients with Established Osteomyelitis MICHAEL P. MULCAHY, ANASTASIA DIMAKOPOULOU, Basildon, United Kingdom This study was performed in a UK general hospital over a 2-year period to investigate the effectiveness of a Diabetologist led diabetic foot MDT. One hundred and eighteen patients with diabetic foot osteomyelitis 656-P sequentially treated at Basildon Hospital Foot service were analysed. Topical Application of the Bee Hive Protectant Propolis Is Well Diagnosis was by plain x-ray, wound exploration, bone biopsy and in Tolerated and Improves Human Diabetic Foot Ulcer Healing in a uncertain cases by MRI scanning (3 cases). 42% of patients were managed Pilot Study exclusively as outpatients. FRANCES R. HENSHAW, THYRA BOLTON, VANESSA L. NUBE, DANIELLE VELD- Mean age was 65 years, mean HbA1c was 60mmol/mol. 36% had CKD 3b HOEN, ANITA HOOD, LOUISE PFRUNDER, GENEVIEVE L. MCKEW, COLIN MAC- and above, 10% were on dialysis. There were 7 major amputations performed LEOD, SUSAN V. MCLENNAN, STEPHEN M. TWIGG, Sydney, Australia by vascular surgeons, 5.9%, approx 3% per year and 47 minor amputations Foot ulcers in diabetes typically have a wound microenvironment of persisting performed by the diabetologist over the 2-year study period. There were infl ammation. Propolis is a naturally occurring anti-infl ammatory substance 88 bone debridements, and these were sent for culture. Most cases of derived from bees applied to hives as a protectant resin. We have published osteomyelitis were polymicrobial with staphylococci and enterococci the that topical propolis improves preclinical cutaneous ulcer healing in a diabetic rat commonest organisms. Vascular assessment was by hand held Doppler. In model. The aim of this study was to determine if propolis shows effi cacy in a pilot 26% CT angiography was also performed. study of human diabetic foot ulcer (DFU) healing and if it is well tolerated. The angiogram result was not permitted to be an indication for major limb Patients with chronic DFU ≥4 week’s duration were enrolled. Propolis was amputation. This decision was based primarily on the progress of the wound. applied at each clinic review for 6 weeks topically to n=23 serial, consenting 10% of patients had a vascular procedure (17 angioplasty, +/- Stents and 1 subjects; 84% male; HbA1c 8.3±1.6%, 73% with Tex1B foot ulcers on oral

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A167 FOOT CARE—LOWER EXTREMITIES

antibiotic. Post-debridement wound fl uid was analyzed for viable bacterial signifi cantly lower in Group 3 (Group 1: 26.6±5.6°, Group 2: 26.0±4.9°, Group count and pro-infl ammatory active MMP-9 level. Ulcer healing data was 3: 23.6±4.7° (Group 3 p<0.05 vs. Group 1 and 2); foot ROM was signifi cantly compared with a matched control cohort of n=88 with DFU of same duration, lower in Group 3 (Group 1: 37.2±6.6°, Group 2: 34.8±1.7°, Group 3: 30.2±1.5° recently treated at the same Centre; 76% male; HbA1c 8.6±2.0%, with (Group 3 p<0.02 vs. Group 1 and 2). There was no difference in vertical 74% Tex.1B DFU on oral antibiotic. Results showed ulcer area starting at ground-reaction forces. When the whole population was considered, a a similar mean ~200mm2 in each group, was reduced by 41% on average positive correlation was apparent between DR presence and severity and in the propolis group compared with 16% in the control group at week 1 SW (r=0.6; p< 0.05) and foot ROM (r=0.65; p< 0.05). Our study demonstrated (P=0.001), and by 63% compared with 44% at week 3 respectively (P<0.05). a positive correlation between biomechanical alterations and presence and POSTERS

Complications In addition, 10% vs. 2% (P<0.001), then 19% vs. 12% (P<0.05) of propolis severity of DR in T2DM, suggesting a possible contribution of microvascular

Acute and Chronic treated vs. control ulcers had fully healed by weeks 3 and 7, respectively. chronic complications in the pathogenesis of FU. Post-debridement wound fl uid active MMP-9 was reduced 18.1% vs. 2.8% by week 3 each from baseline in propolis treated ulcers vs. controls (P<0.001). 659-P Bacterial counts also reduced more rapidly during healing in propolis treated ulcers vs. controls (26% vs. 1%, per 10d; P<0.001). No adverse effects due to WITHDRAWN propolis were reported. This novel study shows that topical propolis therapy is well-tolerated and appears safe in human DFUs and it may enhance wound closure when applied weekly. A multisite randomized controlled of topical propolis in diabetic foot ulcers appears to now be warranted. Supported By: New South Wales Podiatry Board

657-P WITHDRAWN

658-P 660-P Gait Alterations and Microvascular Chronic Complications in Type Reduction in Foot Ulcer Treatment Costs Using Pressure-based In- 2 Diabetic Patients Shoe Orthoses ELISABETTA IACOPI, ROSA GIANNARELLI, ALBERTO COPPELLI, LORENZA JAN S. ULBRECHT, TIMOTHY HURLEY, PETER R. CAVANAGH, State College, PA, ABBRUZZESE, MARTINA VENTURI, GIUSEPPE LAMOLA, DARIO MARTELLI, CAR- Seattle, WA MELO CHISARI, ALBERTO PIAGGESI, Pisa, Italy The purpose of this study was to estimate the potential annual treatment We evaluated gait alterations and their correlations with microvascular cost savings for diabetic foot ulcers (DFUs) in the U.S. associated with use chronic complications in type 2 diabetic patients (T2DM). of orthoses that are custom-designed based on measured barefoot plantar Thirty-six T2DM (M/F: 27/9; age: 63±10 yrs; diabetes duration: 12±11 yrs; pressure versus current standard of care. 2 BMI: 29.2±5.6 Kgm ; HbA1c 8.1±0.9%) attending our outpatient clinic, were DFU occurrence rates from a recently concluded single-blinded multi- divided into 3 Groups: Group 1 (12 pts) with no diabetic neuropathy (DN) and center randomized controlled trial (CareFUL Prevention) were used to model foot ulcerations (FU); Group 2 (10 pts) with DN and no FU; Group 3 (15 pts) the potential impact on DFU treatment costs. In the CareFUL Prevention trial with DN and non-infected, non-ischemic FU. We analyzed biomechanical occurrence of DFUs in high-risk patients with a history of forefoot plantar alterations of lower limbs by motion analysis system (BTS Elite Clinic, BTS neuropathic ulcers were compared between groups randomized to wear Bioengineering, Milan, Italy). Spatial-temporal and kinematics data were orthoses custom designed based on measured barefoot plantar pressure (P) collected through photogrammetric infrared cameras while kinetics data or standard of care HCPCS code A5513 inserts that are custom molded to with two forces plates. Data were correlated with patients’ microvascular the foot with optional modifi cation based on clinical criteria (S). P have been chronic complications; in particular, all patients were examined with indirect previously shown to off-load the forefoot signifi cantly better than S. The and direct retinoscopy and two non-stereoscopic 45° retinal photographs hazard ratio for the occurrence of an ulcer in S compared to P in this study for each eye and presence and severity of retinopathy (DR) was assessed was 3.4 (95%CI 1.3-8.7). Prevalence of diabetic neuropathy, forefoot DFU’s according to the Eurodiab Study classifi cation. and associated treatment costs were estimated from published studies and Step Width (SW) was greater in Group 2 (240.9±47.5 mm) and Group used to model annual DFU treatment costs in the U.S. based on the use of P 3 (271.6±41.7 mm, p<0.02 vs. group 1); ankle range of motion (ROM) was versus S. Costs were projected to 2013 U.S. dollars.

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A168 FOOT CARE—LOWER EXTREMITIES

Applying outcomes from the CareFUL Prevention trial, potential gross DFU 8 (expressed only by neutrophils) was measured by RT-qPCR. In fl uids treatment cost savings in the U.S. was $4.5 billion annually. A sensitivity MMP-9 (total, pro and active forms) and NGAL-MMP-9 protein complex analysis estimated the range of annual cost savings to be between $1.5 were determined by zymography and NGAL level by ELISA. Diabetes and $8.7 billion. On a net cost basis (factoring the additional cost of design signifi cantly increased NGAL and MMP-8 mRNA and wound fl uid NGAL- and fabrication of P orthoses compared to C inserts), the estimated DFU MMP-9 complex as well as all forms of MMP-9 (all >2 fold, P<0.05). Soluble treatment cost savings per 100 high-risk patients was $375,000 annually. NGAL tended to be lower. Insulin treatment normalised NGAL and MMP-8 Use of orthoses custom-designed based on measured barefoot plantar mRNA, total and active MMP-9 and the NGAL-MMP-9 complex. In contrast pressure, that both off-load and prevent forefoot DFUs better than standard Dox treatment had no effect on NGAL mRNA level, partially prevented the POSTERS of care A5513 inserts, have the potential to result in signifi cant prevention of increased MMP-8 and NGAL-MMP-9 complex and had no effect on MMP-9 Complications

DFUs and therefore substantial treatment costs savings. activity. Together these results suggest that higher NGAL levels in diabetic Acute and Chronic Supported By: NIH (2R44DK059074) wounds are related to higher wound fl uid MMP-9 activity. Furthermore therapies targeting NGAL and MMP activities may have utility in diabetic 661-P wound healing. Lower Extremity Function Following Partial Calcanectomy in High- Risk Limb Salvage Patients 663-P NOAH G. OLIVER, JOHN S. STEINBERG, ARASH CHANGIZI, PAUL KIM, CHRISTO- Diabetic Neuropathy (DN) and Amputations at an Endocrinology PHER E. ATTINGER, Washington, DC Service in the Southeast of Brazil Deep heel ulceration with calcaneal osteomyelitis (CO) is a limb SILVIA H. MILLEGO, ALEXANDRE E.F. VIEIRA, MARIA C.R. PARISI, MARIA T.V. threaten ing condition affecting comorbid patients with diabetes. Partial QUILICI, LIGIA O. MATTOS, RAQUEL C.Q. MILLEGO, KAREN C. ALEGRE, RENATA calcanectomy (PC) is an established limb salvage procedure that eradicates G. COSTA, CRISTINA L. SOTO, Sorocaba, Brazil, Campinas, Brazil infection, provides durable soft tissue coverage and offers an alternative to The objective was to identify factors associated with Diabetic Neuropathy amputation. The aim of this study is to assess self-reported lower extremity (DN) and amputations at an Endocrinology Public Service in the southeast function and need for re-amputation following PC and to determine if of Brazil, from June 2012 to July 2013. The cross-sectional study involving these outcomes are infl uenced by the amount of calcaneus that is initially 61patients with type 2 diabetes showed that 61% were female, 75% were resected. white, the mean age was 60,8±10.9 years and the average period of the Retrospective chart review was performed on patients treated at disease was 15 years. The HbA1c was 8.42±2.8%. Out of the 61 patients, Georgetown University Hospital with CO that underwent PC in 2005-2012 49% had DN. There was no statistical difference in the prevalence of DN with 1 year minimal follow-up. The amount of calcaneus resected at PC was according to sex (p=0.245), age (p=0.523), ethnic group (p=0.840), body calculated from the difference in surface area comparing pre-operative and mass index (BMI) (p=0.930), period of disease (p=0.439), hypertension post-operative lateral radiographs using PictZar digital software. Phone (p=0.966), cardiopathy (p=0.413), dyslipidemia (p=0.955), retinopathy interviews were conducted to assess postoperative lower extremity function (p=0.384), visual disability (p=0.432) and nephropathy (p=0.104). Although using the Lower Extremity Function Scale (LEFS). A total of 43 subjects, there was no statistical signifi cance, there was higher prevalence of DN average age 62, were included in the study and divided into 3 cohorts based amongst patients who are or used to be smokers (p=0.081) and in those on the amount of calcaneus resected during PC (see table for results). with claudication (p=0.070). There was statistical association between DN Our fi ndings suggest that PC should be preformed with caution, as high- and the variables: foot wound prior to the study (p<0.001), foot wound at the risk patients requiring PC often require a more proximal amputation and self- moment of the study (p=0.002) and risk factors (foot deformities, plantar report “moderate to quite a bit of diffi culty” on the LEFS, regardless of the ulcers and amputations (p=0.009). DN was associated with previous foot amount of calcaneus resected. wound (p=0.002), claudication (p=0.015) and current or prior smoking Table 1. Results. habits (p=0.055). Nine patients (14,8%) underwent amputation, 6 of them had neuroischemic diabetic foot and 3 had neuropathic diabetic foot; they Cohort 1: Cohort 2: Cohort 3: Total didn’t differ from the others regarding their age, ethnic group, BMI, period 33%-66% of >66% of Subjects calcaneus calcaneus of disease, comorbidities and claudication or pain. Half of the amputated resected resected patients had foot ulcer, while 8.3% of the non-amputated patients had it (p=0.010). The DN was detected in 88.9% of the amputated patients and Body Mass Index (average) 30 30 30 30 in 42.3% of the non-amputated (p=0.012). There were more amputations in Diabetes Mellitus (N/%) 24(83) 7(88) 5(83) 36(84) those who had ulcer and DN. Glycemic control was inadequate, with the Peripheral Vascular Disease (N/%) 17(59) 7(88) 4(67) 28(65) need of improvement in educational advice (with anti-smoking orientation) Healed Partial Calcanectomy (N/%) 15(52) 3(38) 3(50) 20(47) and drug treatment. Revision Calcanectomy (N/%) 4(14) 0 2(33) 6(14) Below Knee Amputation (N/%) 10(34) 5(63) 1(17) 17(40) 664-P Standardized Management of Diabetic Foot in China Lower Extremity Functional Scale (average) 57 22 34 CHUAN YANG, LI YAN, MENG REN, LIFANG MAI, LIU DAN, CHUAN WANG, YICHEN GUO, HUISHEN XIAO, GUOJUAN LAO, YIN LIANG, YIQING QI, HENGCONG LUO, JINLU ZHANG, SHENNENG XUE, THE DIABETIC FOOT STUDY GROUP, Guangzhou, 662-P China, Beijing, China Neutrophil Associated Lipocalin-2 (NGAL) Is Increased and Associ- The treatment of diabetic foot in China so far is not standardized, leading ates with Increased MMP-9 Activity in an Implant Model of Diabetic to the high amputation rate. The diabetic foot patients were system managed Wound Healing by a special group in our hospital and the amputation rate was decreased MARYAM ABDOLLAHI, SARAH AAMIDOR, TARIA NG, ALIREZA REZAEIZADEH, signifi cantly. DANQING MIN, STEPHEN M. TWIGG, SUSAN MCLENNAN, Sydney, Australia Methods: ‘Prevention fi rst, management system, tracking Close’ were Impaired or delayed wound healing in diabetic subjects is associated Established. The diabetes would be managed following the diabetic foot with persistence of infl ammation and increased expression of matrix care pathways. According to the different condition of ulcer, the experts metalloproteinases in particular MMP-9. NGAL (Lipocalin-2) expressed by from endocrinology, orthopedics, plastic surgery et al would provide the activated neutrophils, is known to bind MMP-9 to prevent its degradation. “symphonic”professional treatments, including synthetical internal therapy, We hypothesized that altered wound infl ammatory cell NGAL may play a exhaustive debridement, special dressing, endovascular therapy, NPWT. The role in the increased MMP-9 activities in diabetic wounds. The effects curing patients were followed up closely to prevent ulcer recurrence. of Insulin, or Doxycycline (Dox) as a known inhibitor of MMP-9 activity, Results: The incidence rates of diabetic foot ulcers before and after on wound infl ammatory cell NGALwas also investigated. Diabetes was intensive nursing education were 7.00 vs. 3.70 per 100 person year (P=0.002). induced in Sprague-Dawley rats (D: n=18) with STZ (65mg/kg); some And the diabetic therapeutic shoes could decrease the foot ulcers from 0.30 animals (n=6) were treated with insulin (D+Ins:10IU/day). Six age matched to 0.09 times/person year. Amputation rate, especially in terms of major non-diabetic animals acted as control (C). After six week animals were amputation, was reduced from 30% in 2000 to 2.8% in 2013 signifi cantly anesthetized and PVC sponges (4x1cm2) were implanted subcutaneously; (P<0.0001). The diabetic foot system management would be extended in some diabetic animals (n=6) were treated with oral Dox (20mg/kg). Six Guangzhou and about 40 million Yuan would be saved per year. The input- days later animals were sacrifi ced, sponges were excised and contained output ratio would be 1:27. cells and fl uids separated. The mRNA levels of NGAL, MMP-9 and MMP-

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A169 DIABETESCATEGORY EDUCATION

Conclusion: System management of diabetic foot in China hospital could reduce morbidity rate of ulcers, decrease major amputations and reduce & 666-P expense signifi cantly. Long-term Impact of a School-based Diabetes Education Program on Metabolic Risk Factors in Mexican Patients with Type 2 Diabetes DIANA MARTINEZ, VANESSA MOTA, ALEJANDRO COVARRUBIAS, GEORGINA FLORES, SANDRA LOPEZ, JOSE ANTONIO JACOME, LOURDES RIVAS, JOSE ALBERTO ROJAS, Mexico City, Mexico To analyze the school-based diabetes education program (SDEP) long term impact on metabolic risk factors (MRF) in underserved Mexican patients with type 2 diabetes (T2D) in primary health care. This 12-month, community non-randomized trial in 106 Mexican patients with T2D; all were <70 y.o.; both sexes; with medical treatment according to the ADA/EASD algorithms; did not have severe complications or life- timing illnesses; and had not previously participated in diabetes education courses. The intervention group (n=54) followed the 12 sessions of the SDEP (based on national and international Diabetes Educators Guidelines) and the control POSTERS group (n=52) received usual care (UC). The primary endpoint was HbA1c, and the secondary were: triglycerides (TG), HDL cholesterol (HDL-C), and body weight (BW) (all endpoints defi ned the MRF). Data was collected 3 months before entry to the study (time 0), and at 3, 6, and 12 months. T-paired tests Behavioral Medicine, Clinical

Nutrition, Education, and Exercise estimated the differences from baseline to 12 months follow-up for both study groups. Student´s t- tests evaluated the differences between the two treatment groups for all endpoints at 12 months. In the SDEP group, HbA1C, TG and BW changed signifi cantly (p<0.05): HbA1C by 3, 6 and 12 months from (mean+SD) 7.71+2.05 to 6.90+1.68, 6.80+1.41, and 6.90+1.66; TG by 6 and 12 months from 197.46+133.34 to 165.87+99.18, and 164.76+89.17; and BW by 3 months from 74.36 +13.52 to 73.60 +13.40. The signifi cant changes in the UC group (p<0.005) were: HbA1C Supported By: NSFC (81070660, 81170766, 81270916, 81370910) by 3, 6 and 12 months from 7.16+1.74 to 6.45+1.22, 6.12+0.84, and 6.66+1.42 and TG by 3 months from 150.88+59.81 to 130.48+50.14. After 12 months, no statistically signifi cant differences were observed in the study endpoints DIABETES EDUCATION between the SDEP and UC groups. The SDEP and the UC interventions are both effi cient interventions. The SDEP resulted in greater improvement decreasing HbA1C, TG and BW; Guided Audio Tour: Diabetes Self-Management Education—Partnerships favoring long-term metabolic control. This program may help development and Prevention (Posters: 665-P to 672-P), see page 13. of future educational models.

& 665-P & 667-P A Community-Clinical Partnership for Improving Diabetes Manage- Predictors of Attendance for Diabetes Self-Management Education ment and Outcomes for American Indians Visits in Low Income Latinos with Type 2 Diabetes KATHRYN M. LANGWELL, CATHERINE KEENE, LINDA OGU, MATTHEW M. ZULLO, BRITT ROTBERG, ROBERTO MEJIA, GUILLERMO E. UMPIERREZ, Atlanta, GA Sundance, WY, Fort Washakie, WY, Bethesda, MD Diabetes Education is the mainstay of a successful diabetes care manage- The age-adjusted prevalence of diabetes among American Indians and ment program. Latinos face multiple barriers that impact their diabetes Alaska Natives served by the Indian Health Service is substantially higher care and attendance to follow up visits. We conducted a multivariate than for other racial/ethnic groups in the U.S., at 16.1 percent of the adult logistic regression with backward elimination analysis to predict factors population (NIDDK, 2011). Although there has been considerable attention to for returning to diabetes-self management education classes (DSME) and development of strategies and interventions to reduce diabetes risk factors shared medical appointments (SMA) in Latinos attending the Emory Latino in this population, there has been limited research on the effectiveness of Diabetes Education Program (ELDEP). ELDEP provides DSME classes at Grady these interventions. This paper describes the implementation, evolution, Healthcare System, Atlanta to Latino patients of low socioeconomic status and outcomes of an interventional program designed and conducted by (76.1% earning a household income <$15,000/yr, 66% not having insurance, participating Tribes, in partnership with IHS clinicians, to improve diabetes 57% unable to read and write in Spanish and 94% having limited English management and outcomes for Tribal members with diagnosed diabetes profi ciency). After controlling for demographics (age, gender, education, or pre-diabetes. The interventions included development of culturally- employment, literacy level, insurance), diabetes-related behaviors (history of tailored diabetes self-management education (DSME) programs, training DSME class attendance, exercise, healthy eating, eye exam, fl u vaccination, of Tribal staff to deliver the DSME, followed by 16 weeks of additional dental exam, and foot exam), and biometrics (HbA1c and BMI), the only physical activity based on the Lifestyle Balance program, and creation of variables that were signifi cant factors in predicting patients return to DSME a community-clinical partnership for referrals to the Tribal program and and SMA appointments were: being employed (p<0.05), having an income of sharing of data and resources to support people with diabetes. Evaluation less than $15,000/year (p<0.05), and engaging in physical activity during the of the impact of the initial three years of the program indicate that DSME week (p<0.05) (n=1088). In addition, patients who attended ELDEP 3 month provided by lay health educators, combined with increased communication follow-up classes lowered their HbA1c from 8.8% to 7.7% (p<0.01). and support from Indian Health Service physicians, resulted in statistically These results indicate that patients who are employed, with an income signifi cant increases in confi dence in ability to manage diabetes, positive higher than $15,000/year and engaged in physical activity at least once a changes in self-reported eating patterns and physical activity levels, and week were more likely to return for follow up visits than those who did not. improvements in perceptions of the support from the diabetes care team. Exploring culturally appropriate interventions to foster people with diabetes Clinical outcomes were assessed using pre-post intervention clinical data to become engaged in their follow up care might be a useful tool in improving for 103 program participants who had provided HIPAA authorization for diabetes care in Latinos. release of these data. Findings indicate that that HbA1c levels declined for Supported By: Sanofi 46%, with a decrease in average HbA1c of 1.12 points. Participants with initial HbA1c levels above 12.0 achieved an average reduction of 3.0 points. Supported By: Merck Foundation (256)

For author disclosure information, see page A743. & Guided Audio Tour poster ADA-Funded Research

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