Candida e Bioma ke s o he
P edic ion and Moni o ing o
Pa ial Remission in Pedia ic
Type 1 Diabe es
Laia Gomez-Muñoz
1
, Da id Pe na-Ba ull
1
, Josep M. Ca oz-A mayones
2,3
,
Ma a Mu illo
4
, Sil ia Rod iguez-Fe nandez
1
, Aina Valls
4
, Fede ico Vazquez
5
,
Jacobo Pe ez
6
, Raquel Co ipio
6
, Luis Cas año
7
, Joan Bel
4
and Ma a Vi es-Pi
1
*
1
Immunology Depa men , Ge mans T ias i Pujol Resea ch Ins i u e and Uni e si y Hospi al, Au onomous Uni e si y o
Ba celona, Badalona, Spain,
2
Depa men o Poli ical and Social Sciences, Heal h Inequali ies Resea ch G oup (GREDS-
EMCONET), Pompeu Fab a Uni e si y, Ba celona, Spain,
3
Johns Hopkins Uni e si y–Pompeu Fab a Uni e si y Public Policy
Cen e , Ba celona, Spain,
4
Pedia ics Depa men , Ge mans T ias i Pujol Resea ch Ins i u e and Uni e si y Hospi al,
Au onomous Uni e si y o Ba celona, Badalona, Spain,
5
Endoc inology Depa men , Ge mans T ias i Pujol Resea ch Ins i u e
and Uni e si y Hospi al, Au onomous Uni e si y o Ba celona, Badalona, Spain,
6
Pedia ic Endoc inology Depa men , Pa c
Taulı
´Hospi al Uni e si a i, Ins i u d’In es igacio
´i Inno acio
´Pa c Taulı
´I3PT, Au onomous Uni e si y o Ba celona, Sabadell, Spain,
7
C uces Uni e si y Hospi al, Bioc uces Bizkaia Resea ch Ins i u e, UPV/EHU, CIBERDEM, CIBERER, Endo-ERN, Bilbao, Spain
The pa ial emission (PR) phase, a pe iod expe ienced by mos pa ien s wi h ype 1
diabe es (T1D) soon a e diagnosis, is cha ac e ized by low insulin equi emen s and
imp o ed glycemic con ol. Gi en he g ea po en ial o his phase as a he apeu ic
window o immuno he apies because o i s associa ion wi h immuno egula o y
mechanisms and b-cell p o ec ion, ou objec i e was o find pe iphe al immunological
bioma ke s o i s be e cha ac e iza ion, moni o ing, and p edic ion. The longi udinal
ollow-up o 17 pedia ic pa ien s wi h new-onse T1D o e one yea e ealed ha , du ing
he PR phase, emi e pa ien s show inc eased pe cen ages o e ec o memo y (EM) T
lymphocy es, e minally di e en ia ed EM T lymphocy es, and neu ophils in compa ison
o non- emi e pa ien s. On he con a y, emi e pa ien s showed lowe pe cen ages o
naï e T lymphocy es, egula o y T cells (T
REG
), and dend i ic cells (DCs). A e a yea o
ollow-up, hese pa ien s also p esen ed inc eased le els o egula o y B cells and
ansi ional T1 B lymphocy es. On he o he hand, al hough none o he analyzed
cy okines (IL-2, IL-6, TGF-b1, IL-17A, and IL-10) could dis inguish o p edic emission,
IL-17A was inc eased a T1D diagnosis in compa ison o con ol subjec s, and emi e
pa ien s ended o main ain lowe le els o his cy okine han non- emi e s. The e o e,
hese po en ial moni o ing immunological bioma ke s o PR suppo ha his s age is
go e ned by bo h me abolic and immunological ac o s and sugges immuno egula o y
a emp s du ing his phase. Fu he mo e, since he pe cen age o T
REG
, monocy es, and
DCs, and he o al daily insulin dose a diagnosis we e ound o be p edic o s o he PR
phase, we nex c ea ed an index-based p edic i e model comp ising hose immune cell
pe cen ages ha could po en ially p edic emission a T1D onse . Al hough ou
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254261
Edi ed by:
Te esa Rod iguez-Cal o,
Helmhol z Associa ion o Ge man
Resea ch Cen es (HZ), Ge many
Re iewed by:
Isabelle Se ,
Helmhol z Associa ion o Ge man
Resea ch Cen es (HZ), Ge many
Lau a M. Jacobsen,
Uni e si y o Flo ida, Uni ed S a es
*Co espondence:
Ma a Vi es-Pi
[email p o ec ed]
Special y sec ion:
This a icle was submi ed o
Au oimmune and
Au oinflamma o y Diso de s,
a sec ion o he jou nal
F on ie s in Immunology
Recei ed: 30 No embe 2021
Accep ed: 31 Janua y 2022
Published: 23 Feb ua y 2022
Ci a ion:
Gomez-Muñoz L, Pe na-Ba ull D,
Ca oz-A mayones JM, Mu illo M,
Rod iguez-Fe nandez S,
Valls A, Vazquez F, Pe ez J,
Co ipio R, Cas año L, Bel J
and Vi es-Pi M (2022) Candida e
Bioma ke s o he P edic ion and
Moni o ing o Pa ial Remission in
Pedia ic Type 1 Diabe es.
F on . Immunol. 13:825426.
doi: 10.3389/ immu.2022.825426
ORIGINAL RESEARCH
published: 23 Feb ua y 2022
doi: 10.3389/ immu.2022.825426
p elimina y s udy needs u he alida ion, hese candida e bioma ke s could be use ul o
he immunological cha ac e iza ion o he PR phase, he s a ifica ion o pa ien s wi h
be e disease p ognosis, and a mo e pe sonalized he apeu ic managemen .
Keywo ds: ype 1 diabe es (T1D), pa ial emission phase, honeymoon, bioma ke s, pedia ics, p edic ion model,
immune cell subpopula ions, au oimmuni y
INTRODUCTION
Type 1 diabe es (T1D) is an au oimmune T-cell-media ed
disease agains panc ea ic b-cells, which leads o he
insu ficien p oduc ion o insulin and o e hype glycemia (1).
This ch onic me abolic disease a ec s a g owing numbe o
child en and adolescen s (2), and because o he b-cell unc ion
decay, pa ien s ely on exogenous insulin he apy o li e,
which only delays he appea ance o long- e m seconda y
complica ions. Al hough i s exac e iology and pa hogenesis a e
s ill elusi e, he de elopmen o T1D in ol es complex
in e ac ions be ween b-cells and inna e and adap i e immune
cells, namely, T and B lymphocy es, NK cells, monocy es,
dend i ic cells (DCs), and neu ophils (3). Di e en s a egies
capable o s opping he au oimmune p ocess and p omo ing b-
cell eco e y ha e been de eloped in expe imen al models, bu
none o hem has achie ed o al emission in humans o
managed o p e en o cu e he disease (4,5). This ailu e
could be pa ially explained by he lack o an op imal
checkpoin o immune in e en ions, and he insu ficien
bioma ke s o he p ope s a ifica ion o pa ien s, an unme
need in clinical ials (6,7).
As o his las poin , sho ly a e diagnosis and he ini ia ion
o insulin he apy, be ween 50 and 80% o pa ien s wi h T1D
expe ience a ansien pa ial emission (PR) pe iod, also called
he honeymoon phase, which is ma ked by low equi emen s o
exogenous insulin and diminished glyca ed hemoglobin
(HbA1c) le els (8). This s age, cha ac e ized by me abolic and
immunological al e a ions, could cons i u e a unique window o
he apeu ic in e en ions. This pe iod can las om weeks o
yea s wi h an a e age o 9 mon hs o du a ion (9), bu in some
uncommon cases, a comple e o long-las ing emission has been
desc ibed (10,11). Pa ien s wi h his imp o ed glucose con ol
may be a a lowe isk o he sho - and long- e m complica ions
o T1D, such as ch onic mic o ascula complica ions.
Un o una ely, he mechanisms unde lying he PR phase
a e poo ly cha ac e ized, bu his na u al phenomenon has
been a ibu ed o bo h he educ ion o glucose oxici y a e
he ini ia ion o he insulin he apy and he consequen b-cell
es , eco e y, and egene a ion wi h imp o ed endogenous
insulin p oduc ion (12). A a clinical le el, bica bona e
concen a ions >15 mg/dl, age >5 yea s, male sex, highe body
mass index (BMI) alues, lowe HbA1c le els, and <3 diabe es-
associa ed au oan ibodies can p edispose o PR in child en and
adolescen s wi h new-onse T1D (13,14). Fu he mo e,
mechanisms o immune egula ion a e non-linea along he
na u al his o y o T1D—ma ching well wi h he p oposed
elapsing- emi ing cha ac e o he disease cou se—and he
PR phase is associa ed wi h hese immunomodula o y changes
(15,16). Consis en wi h his idea, s udies in es iga ing changes
in immune pa ame e s ha e epo ed ha pa ien s wi h he
highes equency o CD4
+
CD25
+
CD127
hi
lymphocy es a
disease onse expe ience he longes PR (17,18), ha inc eased
le els o egula o y T, B, and NK cells can be ound du ing T1D
p og ession (which could eflec a emp s a es o ing sel -
ole ance) (19,20), and ha he absence o IL-4, TNF-a, IL-10,
and IL-13 in se a co ela es wi h he leng h o he emission
pe iod (21). In e es ingly, pe iphe al an igen-specific egula o y
T cells (T
REG
) diminish du ing he honeymoon phase in
compa ison o he ime o diagnosis (22). Ne e heless, ew
s udies ha e compa ed pa ien s wi h and wi hou PR o find
specific and eliable bioma ke s o his phase.
Non-in asi e app oaches like he use o pe iphe al blood
samples a e essen ial o iden i y bioma ke s o T1D p og ession
and emission. Since many s udies ha e shown ha he
p og ession o T1D is associa ed wi h changes in immune
pa ame e s, bu he longi udinal da a including he analysis o
he PR phase is sca ce (15,20,21,23–27), he p esen s udy was
aimed a analyzing he pe cen age and absolu e coun s o inna e
and adap i e immune cell subse s in pe iphe al blood and he
concen a ion o di e en cy okines in plasma o e one yea a e
T1D diagnosis, di e en ia ing pa ien s wi h and wi hou PR o
find specific moni o ing and p edic i e bioma ke s o his s age.
These bioma ke s could be o g ea in e es o cha ac e ize he
immunological mechanisms behind he PR phase and b-cell
p o ec ion, o moni o he ea ly cou se o T1D, and o s a i y
pa ien s wi h be e disease p ognosis a he onse o he disease o
hei selec ion in clinical ials. Mo eo e , in he case o non-
emi e s, hese bioma ke s would allow o a mo e pe sonalized
he apeu ic managemen o ensu e he p e en ion o ea ly
hype glycemia and o educe he isk o seconda y complica ions.
MATERIALS AND METHODS
Pa icipan s
Fo he longi udinal s udy o T1D p og ession and he
cha ac e iza ion o he PR phase, 17 pedia ic pa ien s wi h
Abb e ia ions: AUC, A ea Unde he Cu e; BMI, Body Mass Index; B
REG
,
Regula o y B Cells; CM, Cen al Memo y; DCs, Dend i ic Cells; EM, E ec o
Memo y; GAD65, Glu amic Acid Deca boxylase 65; HbA1c, glyca ed hemoglobin;
IA-2, Insulinoma An igen-2; IDAA1c, Insulin-Dose Adjus ed HbA1c; mDCs,
Myeloid Dend i ic Cells; pDCs, Plasmacy oid Dend i ic Cells; PR, Pa ial
Remission; ROC, Recei e Ope a ing Cha ac e is ic; SDS, s anda d de ia ion
sco e; T1D, Type 1 Diabe es; TEMRA, e minally di e en ia ed e ec o memo y
T; T
REG
,Regula o yTCells;VIF,Va ianceInfla ion Fac o s; ZnT8, Zinc
T anspo e 8.
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254262
new-onse T1D (o which 16 comple ed he s udy) and 17 age-
and sex-ma ched non-diabe ic con ol subjec s we e included.
Fo he PR p edic i e model, 10 addi ional pedia ic pa ien s only
a T1D onse (n= 27) we e selec ed.
All pa ien s ulfilled he Ame ican Diabe es Associa ion
classifica ion c i e ia o T1D (28), wi h a leas one posi i e
an i-isle au oan ibody a disease onse [ o insulinoma-an igen 2
(IA-2), glu amic acid deca boxylase 65 (GAD65), o zinc
anspo e 8 (ZnT8)]. Inclusion c i e ia we e 4–18 yea s o age
and no mal BMI acco ding o he Spanish BMI pedia ic coho
g ow h cha (29). Exclusion c i e ia we e being unde
immunosupp essi e o an i-inflamma o y ea men , ype 2
diabe es, p egnancy, comp omised kidney unc ion, o li e
diseases. Also, candida es we e excluded i hey p esen ed
mode a e/se e e symp oma ic in ec ions o e e in he
p e ious 2–4 weeks be o e blood wi hd awal (i.e., Flu o
Co id-19).
Sample Collec ion, Longi udinal T1D
Follow-Up, and PR
Longi udinal T1D da a collec ion occu ed o e one yea in wo
Uni e si y Hospi als. Blood samples o 6 ml we e ob ained a
h ee di e en ime-poin s h oughou T1D p og ession o each
pa ien : a disease onse (n= 17), a PR (n= 11) o 8 mon hs o
non- emi e pa ien s (n= 6), and a 12 mon hs a e disease
onse (n= 16) in EDTA ubes (BD Biosciences, San Jose, CA,
USA) and p ocessed wi hin 6 h. Con ol samples o 6 ml o blood
om non-diabe ic subjec s (sex and age- ela ed, and wi h he
same exclusion c i e ia) we e acqui ed simul aneously o he
diagnosis o child en wi h T1D. In addi ion, non-longi udinal
blood samples o 3 ml om 10 pa ien s only a T1D onse (6
u u e emi e s, 4 u u e non- emi e s) we e ob ained o he
gene a ion o he PR p edic i e model and p ocessed as abo e. A
disease onse , all samples (n= 27) we e collec ed be ween 1 and
14 days a e diagnosis. A e he mon hly medical isi , pa ien s
we e conside ed o be in PR when hey ulfilled he accep ed
c i e ia o ≤9 insulin dose-adjus ed HbA1c (IDAA1c), an index
ha is calcula ed as HbA1c (%) + [4 × insulin dose (U/kg/day)]
(30). This phase was iden ified be ween 2 and 6 mon hs a e
diagnosis, and indi iduals who did no mee he c i e ia o PR
a e 8 mon hs, we e defined as non- emi e s.
Clinical and Labo a o y Tes ing
Clinical desc ip o s on each pa ien and con ol subjec we e
collec ed, namely, age, sex, and BMI. BMI da a we e also
exp essed as s anda d de ia ion sco e (SDS) o age and sex,
based on he Spanish BMI pedia ic coho g ow h cha da a
(29). Blood samples om pa ien s wi h T1D we e acqui ed o
cen alized measu emen o HbA1c, as ing basal and s imula ed
C-pep ide, gene ics, and immunology; and insulin equi emen s
we e eco ded. A he ime o T1D diagnosis, HLA yping o
DRB1 alleles and isle au oan ibodies o IA-2, GAD65, and ZnT8
we e de e mined as p e iously epo ed (20). HbA1c was
de e mined by high-pe o mance liquid ch oma og aphy
(ADAMS A1c HA-8180V, A k ay, MN, USA) in all pa ien s a
each ime-poin . Fas ing basal C-pep ide was de e mined by
ELISA (A chi ec i2000, Abbo , IL, USA) in bo h con ols and
pa ien s a each ime-poin . Only a T1D onse , s imula ed C-
pep ide was measu ed 6 min a e i. . adminis a ion o 1
mg glucagon.
Flow Cy ome y
Pheno ypic analysis o cellula subpopula ions was pe o med in
con ol subjec s and pa ien s wi h T1D a each ime-poin . To
ha end, esh whole blood samples o 1–2 ml we e washed wi h
15 ml o FACSFlow Shea h Fluid (The moFishe Scien ific,
Wal ham, MA, USA), and 100 ml we e s ained wi h specific
mAbs o 20 min a oom empe a u e and p o ec ed om ligh .
The panels o an ibodies (Supplemen al Tables 1, 2) we e buil
as ollows: (1) T lymphocy e ma u a ion s ages panel: CD3-
V500, CD4-Pe CPCy5.5, CD8-APCH7, CD45RA-FITC, PTK7-
PE, CCR7-PECy7, CD31-AF647, CD27-BV421, (2) T
REG
panel:
CD45-FITC, CD3-V450, CD4-Pe CPCy5.5, CD25-PE, CCR4-
PECy7, CD127-AF647, CD45RO-APCH7, HLA-DR-V500, (3)
T
H
17 lymphocy es panel: CD4-V450, CCR6-PE, CCR7-PECy7,
and CCR4-AF647, (4) TCR panel: CD3-Pe CP, gd TCR-PE, ab
TCR-FITC, CD8-APCH7, CD4-V450, (5) B lymphocy e
ma u a ion s ages panel: CD3-V450, CD19-V500, CD27-APC,
CD21-PE, IgD-FITC, IgM-Pe CPCy5.5, (6) Blymphocy e
subpopula ions panel: CD19-Pe CPCy5.5, CD24-FITC, CD38-
PE, CD27-APC, and (7) Inna e cells panel: CD45-AF700, CD3-
APCH7, CD19-APCH7, CD14-V450, CD16-APC, CD11c-
PECy7, CD123-Pe CPCy5.5, CD56-PE, HLA-DR-V500, Slan-
FITC. A e incuba ion, e y h ocy es we e lysed o 7 min
(Lysing Bu e , BD Biosciences). Samples we e hen washed
and esuspended in FACSFlow Shea h Fluid (The moFishe
Scien ific). Absolu e coun s (cells/ml) o leukocy es and
lymphocy es we e ob ained using Pe ec Coun Mic osphe es
o known concen a ion (Cy ognos SL, Salamanca, Spain).
A minimum o 10,000 e en s pe sample and 5,000 beads
we e acqui ed using a 3-lase FACS Can o II and a 4-lase LSR
Fo essa Flow Cy ome e s (BD Biosciences) and analyzed using
FACSDi a so wa e (BD Biosciences). Nec o ic and apop o ic
cells we e excluded om he analysis based on hei FSC-A/SSC-
A p ope ies and double s we e excluded by FSC-A/FSC-H. The
ga ing s a egy o analyze specific leukocy e subse s was based on
in e na ional consensus (31). Fluo escence minus one con ols
we e used o define CCR7 exp ession on T
H
17 lymphocy es and
PTK7 exp ession on ecen hymic emig an s. Fu he mo e,
in e nal e e ence popula ions we e used as posi i i y con ols
in he analysis o CCR7 s. CD45RA in panel 1, CD27 s. CD24
in panel 2, CD19 s. CD21 in panel 3, CCR4 s. CCR7 in panel 4,
and CD45RO s. CCR4 plus CD45RO s. HLA-DR in panel 5.
Absolu e coun s we e calcula ed as ollows: (%subse /100) ×
coun s o he main subpopula ion.
Se um Cy okine Quan ifica ion
Plasma samples we e ob ained a e cen i uging 4–5 ml o whole
blood samples wice a 4°C wi hin he fi s hou a e
enipunc u e (1,900 G o 10 min; 16,000 G o 10 min) and
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254263
s o ed a −80°C un il use. The BD Cy ome ic Bead A ay (CBA)
Human Enhanced Sensi i i y Flex Se s o IL-2, IL-6, IL-10, and
IL-17A (BD Biosciences) we e used o measu e cy okine
concen a ion (de ec ion ange 274–200,000 g/ml). Samples
we e acqui ed on an LSR Fo essa flow cy ome e (BD
Biosciences), and da a we e analyzed using CBA so wa e. The
Human TGF-b1 ELISA Ki (FineTes , Wuhan Fine Bio ech,
Wuhan, China) was used o he quan ifica ion o TGF-b1
(de ec ion ange 31.25–2,000 pg/ml; sensi i i y 18.75 pg/ml).
S a is ical Analysis
Da a we e es ed o no mal dis ibu ion wi h he Shapi o–Wilk
es and a e p esen ed as mean ± SD, mean (min, max), o median
and in e qua ile ange, unless s a ed o he wise. Fo clinical
pa ame e s, a desc ip i e s a is ical analysis o he a iables was
pe o med. c² es was used o ca ego ical a iables. Di e ences
be ween wo g oups we e analyzed using he nonpa ame ic 2-
ailed Wilcoxon es o pai ed da a and he nonpa ame ic 2- ailed
Mann–Whi ney es o unpai ed da a. To es di e ences among
longi udinal da a, a mixed e ec s model was fi wi h condi ion as
fixed e ec , and indi idual and esidual andom a ia ion as
andom e ec co a ia es oge he wi h he Tukey’s mul iple
compa isons es . K uskal–Wallis es ollowed by Dunn’s
mul iple compa isons es was used o compa e da a be ween
con ol subjec s and each ime-poin o T1D p og ession. To
es ablish associa ions be ween immunological, clinical, and
me abolic a iables and he occu ence o PR, simple logis ic
eg essions we e de eloped. Samples wi h missing da a we e
emo ed. The OR wi h he 95% CI was epo ed as a p obabili y
measu e. Recei e -ope a ing cha ac e is ic (ROC) cu es we e
gene a ed om he logis ic eg essions o ob ain he a ea unde
he cu e (AUC), which is use ul o assess he disc imina ion abili y
o he a iables. G- es o goodness-o -fi was also employed. To
gene a e a ull model con aining simul aneously he s a is ically
significan immunological a iables, an index was c ea ed om he
bes cu -o alues o he ROC cu es o each a iable. Simple and
mul iple logis ic eg essions (adjus ed by BMI-SDS) we e gene a ed
o assess he associa ion be ween he index and he e en o PR. The
ela ionship be ween co a ia es was de e mined wi h linea
eg essions. To check he obus ness o he esul s, mul icollinea i y
was examined by he a iance infla ion ac o s (VIF), R
2
wi h o he
a iables, and Spea man’s co ela ions be ween he selec ed a iables.
To find s a is ically significan co ela ions be ween di e en
pa ame e s, a wo- ailed Spea man’s o Pea son’s es was used. All
analyses we e pe o med wi h G aphPad P ism 9.0 (G aphPad
So wa e Inc, San Diego, CA, USA) and S a a 16.0 (S a a
Co po a ion, College S a ion, TX, USA). A P- alue o ≤0.05 was
conside ed s a is ically significan .
RESULTS
Clinical Fea u es and Me abolic Da a o
Pedia ic Pa ien s Wi h T1D
Clinical ea u es and me abolic da a om con ol subjec s and
pa ien s wi h T1D a each ime-poin o he longi udinal s udy a e
summa ized in Table 1. No s a is ically significan di e ences we e
TABLE 1 | Clinical ea u es and me abolic da a o con ol subjec s and pa ien s wi h T1D included in he longi udinal s udy.
Con ol subjec s (n= 17) T1D onse (n= 17) Remi e T1D pa ien s (n= 11) Non- emi e T1D pa ien s (n=6)
Baseline Baseline PR (2–6 mon hs a e baseline) 12 mon hs a e baseline 8 mon hs a e baseline 12 mon hs a e baseline
Age (yea s) 8.8 ± 3.4 8.7 ± 3.6 9.1 ± 4.3 10.2 ± 4.3**
,xx
9 ± 2.8 9.2 ± 2.8*
Sex (M/F) 7/10 7/10 5/6 4/6 2/4 2/4
BMI (kg/m
2
) 18.3 ± 4.3 16.8 ± 2.5 17.7 ± 3* 18.6 ± 3.5* 17.2 ± 2.1 17 ± 1.9
BMI-SDS 0.04 (−1.7, 2.7) −0.5 (−1.6, 0.7) −0.2 (−1.2, 1.1)* −0.1 (−1.0, 1.6) −0.4 (−1.1, 0.3) −0.5 (−1.0, 0.2)
HbA1c (%) NA 11.4 ± 2.4 6.9 ± 0.6** 7.1 ± 0.8**/
^
8.1 ± 0.7*/
xx
7.9 ± 0.9*/
x
HbA1c (mmol/mol) NA 101.3 ± 26.2 51.5 ± 6.4** 54.2 ± 9.1**/
^
64.5 ± 7.4*/
xx
63 ± 10.1*/
x
Insulin dose (U/Kg/day) NA 0.7 ± 0.2 0.4 ± 0.1** 0.5 ± 0.2
^^^
0.9 ± 0.1
xxx
0.85 ± 0.1
xxx
/°°
Basal C-pep ide (ng/ml) 1.3 ± 0.4 0.3 ± 0.2
++++
0.7 ± 0.5
++
0.3 ± 0.3
++++
0.3 ± 0.1
+++
0.15 ± 0.06
+++
/
xx
S imula ed C-pep ide (ng/ml) NA 0.6 ± 0.4 ND ND ND ND
IDAA1c NA 14.3 ± 3 8.4 ± 0.5** 9.2 ± 1.3**/
^^
11.5 ± 1*/
xxx
11.3 ± 1.2*/
xxx
/°°
Da a p esen ed as mean ± SD, o mean (min, max). P- alue calcula ed om Mann–Whi ney es when compa ing con ol subjec s and pa ien s wi h T1D (
++
P≤0.01,
+++
P≤0.001 and
++++
P≤0.0001), and emi e and non- emi e g oups
[
x
P≤0.05,
xx
P≤0.01 and
xxx
P≤0.001 o compa ison wi h PR; ^P ≤0.05, ^^P ≤0.01 and ^^^P ≤0.001 o compa ison wi h 8 mon hs a e baseline (non- emi e s); and °°P ≤0.01 o compa ison wi h 12 mon hs a e baseline ( emi e s)]. P-
alue calcula ed om Wilcoxon es o compa isons o pai ed da a wi h disease onse (*P ≤0.05 and **P ≤0.01). BMI, Body Mass Index; F, emale; HbA1c, glyca ed hemoglobin; IDAA1c, insulin dose-adjus ed HbA1c; M, male; NA, no
applicable; ND, no de e mined; SDS, s anda d de ia ion sco e.
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254264
ound in age and BMI when compa ed be ween con ol subjec s
and pa ien s a T1D onse ; as expec ed, hey we e ound in e ms o
plasma C-pep ide concen a ion (1.3 ± 0.4 s 0.3 ± 0.2; P<0.0001).
The 64.7% o pa ien s wi h T1D p esen ed PR be ween 2 and
6 mon hs a e he diagnosis, wi h an IDAA1c alue equal o o
less han 9, while he es did no expe ience i a e 12 mon hs o
ollow-up. Du ing he PR phase, and in compa ison o disease
onse , pa ien s showed inc eased BMI and BMI-SDS alues, and
a non-significan inc ease in basal C-pep ide concen a ion (0.7 ±
0.5 s 0.3 ± 0.2; ns), al hough he le els we e s ill much lowe han
hose o he con ol g oup (0.7 ± 0.5 s 1.3 ± 0.4; P<0.01). A e a
yea ollow-up, 50% o hese emi e pa ien s we e s ill in
emission. The e we e no significan di e ences in e ms o age,
sex, and BMI be ween pa ien s wi h and wi hou PR a 8 mon hs o
ollow-up. Unlike pa ien s in emission, non- emi e pa ien s
(IDAA1c >9) did no p esen an inc ease in basal C-pep ide
concen a ion a e diagnosis (0.3 ± 0.1 s 0.3 ± 0.2; ns),
indica ing some b-cell eco e y only in emi e pa ien s.
A e 12 mon hs o ollow-up, he g oup o emi e pa ien s
showed lowe le els o basal C-pep ide han le els du ing
emission; howe e , hese doubled hose o he non- emi e s
(0.3 ± 0.3 s 0.15 ± 0.06; ns). Mo eo e , he g oup o emi e
pa ien s s ill needed a lowe daily dose o o al insulin han he
g oup o non- emi e pa ien s (0.5 ± 0.2 s 0.85 ± 0.1; P<0.01)
and main ained he inc eased BMI alues ega ding he disease
onse (18.6 ± 3.5 s 16.8 ± 2.5; P≤0.05). A 12 mon hs, bo h
emi e s and non- emi e s main ained p ac ically equal he
HbA1c alues eached du ing he PR phase o a 8 mon hs om
diagnosis, espec i ely.
Clinical ea u es and me abolic da a om pa ien s wi h T1D
a disease onse o he PR p edic i e s udy a e summa ized in
Table 2. Di e ences a T1D onse be ween emi e s and non-
emi e s we e ound in e ms o insulin dose (0.6 ± 0.2 s 0.8 ±
0.1, P<0.01) and s imula ed C-pep ide (0.9 ± 0.8 s 0.5 ± 0.5,
P≤0.05).
Inc ease in E ec o Memo y CD4
+
and
CD8
+
T Lymphocy es a he PR Phase
Figu e 1 shows he ga ing s a egy ollowed o he an ibody
panels o T lymphocy e ma u a ion s ages and T
REG
. The analysis
o he ma u a ion s ages o bo h CD4
+
and CD8
+
T lymphocy es
(naï e, cen al memo y (CM), e ec o memo y (EM), and
e minally di e en ia ed e ec o memo y T (T
EMRA
)
lymphocy es), e ealed s a is ically significan changes in blood
om pa ien s du ing he PR phase (Figu e 2).
Rega ding CD4
+
T lymphocy es, non- emi e pa ien s
p esen ed highe pe cen ages o naï e CD4
+
Tlymphocy es
bo h a 8 and 12 mon hs in compa ison o pa ien s a disease
onse (P≤0.05) (Figu e 2A). While he pe cen age o CM CD4
+
T lymphocy es ended o inc ease wi h disease p og ession o
he emi e ones—especially a 12 mon hs a e T1D onse in
compa ison o he diagnosis and he con ol g oup (P<0.001)—
he pe cen age o his subpopula ion ended o dec ease a 12
mon hs o non- emi e pa ien s in compa ison o he ime-
poin o 8 mon hs, whe e le els we e also highe han hose
o he con ol g oup (P≤0.05). Howe e , no significan
di e ences we e obse ed be ween emi e s and non- emi e s
a 8 mon hs (Figu e 2B).
The main findings obse ed du ing he PR phase when
compa ed wi h non- emi e pa ien s we e highe pe cen ages
o EM and ea ly EM CD4
+
T lymphocy es and CD8
+
T
EMRA
lymphocy es (Figu es 2D, E, H). The pe cen age o CD4
+
T
EMRA
lymphocy es dec eased a 12 mon hs o emi e pa ien s in
compa ison o con ols (P≤0.05), bu ended o be highe du ing
he PR phase in compa ison o non- emi e s a 8 mon hs
(Figu e 2C). Pe iphe al EM and ea ly EM CD4
+
T
lymphocy es beha ed simila ly (Figu es 2D, E). The
pe cen ages o bo h subpopula ions we e significan ly inc eased
du ing he PR phase in compa ison o 8 mon hs (P≤0.05 and
P<0.01, espec i ely) and 12 mon hs (P≤0.05) o non- emi e
pa ien s. The la e ones a 8 mon hs also showed dec eased
pe cen ages in compa ison o disease onse (P<0.01) and con ol
subjec s (P≤0.05 and P= 0.06, espec i ely), and a 12 mon hs
han pa ien s a diagnosis (P≤0.05 and P<0.01, espec i ely).
Conce ning he absolu e coun s, only CD4
+
T
EMRA
lymphocy es significan ly inc eased du ing he PR phase in
compa ison o 8 mon hs o non- emi e s. No o he
significan di e ence was obse ed be ween pa ien s wi h and
wi hou PR (Supplemen al Figu es 1A–E).
Rega ding CD8
+
T lymphocy es, pa ien s a he PR phase
p esen ed lowe pe cen ages o naï e CD8
+
T lymphocy es
TABLE 2 | Clinical ea u es and me abolic da a o pa ien s wi h T1D included in he PR p edic i e model s udy a disease onse sepa a ed by u u e emi e s and non- emi e s.
T1D onse ( u u e PR) (n= 17) T1D onse ( u u e non-PR) (n= 10) P- alue
Age (yea s) 9.8 ± 5 6.4 ± 3.4 0.07
Sex (M/F) 8/9 4/6 0.72
BMI (kg/m
2
) 17.7 ± 3.0 15.7 ± 1.7 0.12
BMI-SDS −0.5 (−1.8, 0.7) −0.7 (−1.7, 0.5) 0.54
HbA1c (%) 11.1 ± 2.5 11.4 ± 1.7 0.61
HbA1c (mmol/mol) 98.1 ± 27.5 100.6 ± 18.6 0.61
Insulin dose (U/Kg/day) 0.6 ± 0.2 0.8 ± 0.1 0.01**
Basal C-pep ide (ng/ml) 0.4 ± 0.3 0.3 ± 0.2 0.15
S imula ed C-pep ide (ng/ml) 0.9 ± 0.8 0.5 ± 0.5 0.03*
IDAA1c 14.5 ± 3.2 14.7 ± 2.0 0.98
Da a p esen ed as mean ± SD, o mean (min, max). P- alue calcula ed om Mann–Whi ney es when compa ing baseline ime-poin s (T1D onse ) be ween emi e s and non- emi e s
(*P ≤0.05 and **P ≤0.01). BMI, Body Mass Index; F, emale; HbA1c, glyca ed hemoglobin; IDAA1c, insulin dose-adjus ed HbA1c; M, male; SDS, s anda d de ia ion sco e.
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254265
compa ed o pa ien s wi hou PR a 8 mon hs (P≤0.05).
Mo eo e , non- emi e pa ien s showed a highe pe cen age o
his subpopula ion han con ols (P<0.01) (Figu e 2F). Con a y
o wha was obse ed in he CM CD4
+
Tlymphocy e
subpopula ion, he pe cen age o CM CD8
+
T lymphocy es
ended o dec ease wi h T1D p og ession and showed a
significan inc ease a disease onse compa ed o he con ol
g oup (P<0.01) (Figu e 2G). As men ioned be o e, he
pe cen age o CD8
+
T
EMRA
lymphocy es was lowe a 8
mon hs o non- emi e pa ien s in compa ison o pa ien s a
he PR phase (P≤0.05) and con ols (P≤0.05) (Figu e 2H).
Las ly, and ega ding he pe cen age o EM and ea ly EM CD8
+
T
FIGURE 1 | Rep esen a i e ga ing s a egy o he T lymphocy e ma u a ion s ages and T
REG
panels. Ga ing s a egy used o analyze he pe cen ages o he
di e en CD4
+
and CD8
+
T cell subse s based on he exp ession o he ma ke s CD3, CD4, CD8, CD45RA and CCR7, and o CD127, CD25, CD45RO, CCR4 and
HLA-DR o T
REG
subse s wi hin CD4
+
T cells. CD31 and PTK7 we e used o cha ac e ize RTEs. Posi i i y con ols o CCR7 s CD45RA using lymphocy es, o
CD45RO s CCR4 using CD4
-
T cells and o CD45RO s HLA-DR using CD4
+
T cells as in e nal e e ence popula ions. FMO con ol o PTK7 was used.
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254266
lymphocy es, no di e ences we e ound be ween g oups
(Figu es 2I, J).
Conce ning he absolu e coun s o hese subse s, no
significan di e ences we e ound be ween pa ien s wi h and
wi hou PR (Supplemen al Figu es 1F–J).
As o o al CD4
+
T lymphocy es, hei pe cen age inc eased
a 8 mon hs o non- emi e pa ien s when compa ed o pa ien s
du ing he PR phase (P<0.01), o emi e pa ien s a 12 mon hs
o ollow-up (P≤0.05) and con ols (P≤0.05), bu no di e ences
be ween emi e s and non- emi e s we e ound ega ding hei
absolu e numbe s (Supplemen al Figu es 2A, B). Conce ning
he absolu e coun s and pe cen ages o o al CD8
+
T
lymphocy es, la e EM CD4
+
and CD8
+
T lymphocy es, ecen
hymic emig an s, gd TCR cells, and T
H
17 lymphocy es, no
significan di e ences we e ound be ween pa ien s wi h and
wi hou PR (Supplemen al Figu es 2C–N). Ga ing s a egies o
AB
DE
FG
IHJ
C
FIGURE 2 | Pe cen ages o CD4
+
and CD8
+
T lymphocy e subse s a e al e ed a he ini ial s ages o T1D. Fo CD4
+
and CD8
+
T lymphocy es, espec i ely, he
pe cen ages (%) o (A, F) naï e T lymphocy es, (B, G) CM T lymphocy es, (C, H) T
EMRA
lymphocy es, (D, I) EM T lymphocy es, and (E, J) ea ly EM T lymphocy es
we e de e mined in pe iphe al blood o con ol subjec s and pa ien s wi h T1D a di e en ime-poin s. Squa es ep esen con ols (n= 17) (whi e ba ), and pa ien s
a e ep esen ed by ligh g ay do s a disease onse (n= 17) (g ay ba ), whi e do s du ing PR (n= 11) and o emi e pa ien s a 12 mon hs (12 M PR) (n= 10) (blue
ba s), and da k g ay do s o non- emi e pa ien s a 8 mon hs (8 M no PR) (n= 6) and 12 mon hs (12 M no PR) (n= 6) (pink ba s). Ba g aphs show mean
pe cen age alues. Each symbol ep esen s an indi idual pa ien . Lines link he same pa ien h oughou he ime-poin s. *P≤0.05, **P<0.01, ***P<0.001 a e
mixed e ec s model wi h Tukey’s pos -hoc es o longi udinal da a, K uskal–Wallis wi h Dunn’s pos -hoc es o compa isons be ween con ol subjec s and he
di e en T1D ime-poin s, o 2- ailed Mann–Whi ney es o compa isons be ween wo unpai ed g oups o da a. P≤0.05 is conside ed significan .
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254267
he an ibody panels o TCR and T
H
17 lymphocy es a e depic ed
in Supplemen al Figu es 3, 4.
Dec ease in To al and Memo y T
REG
a
he PR Phase
Since T
REG
a e expec ed o be implica ed in he immuno egula o y
mechanism behind he PR phase (32), we analyzed pe iphe al
T
REG
subse s, namely, o al, memo y, and ac i a ed T
REG
.
Fu he mo e, ep esen a i e confi ma o y s aining o FoxP3
wi hin he T
REG
popula ion can be ound in Supplemen al
Figu e 5, whe e 74.6% o hese cells do exp ess i .
The main findings obse ed in pa ien s wi h T1D a he PR
phase when compa ed wi h pa ien s wi hou he PR we e lowe
pe cen ages o bo h o al and memo y T
REG
(Figu es 3A, C).
Specifically, he pe cen age o o al T
REG
inc eased a 8 mon hs
om diagnosis o pa ien s wi hou PR in compa ison wi h bo h
he con ol g oup (P≤0.05) and pa ien s a disease onse (P≤0.05).
Fu he mo e, le els a his ime-poin a e highe han pa ien s in
PR, bo h du ing ha phase (P≤0.05) and 12 mon hs a e
diagnosis (P≤0.05). A e a yea ollow-up, pa ien s who did no
p esen PR con inued o show a highe pe cen age o o al T
REG
han pa ien s who p esen ed emission (P≤0.05) (Figu e 3A).
Rega ding hei absolu e numbe s, o al T
REG
inc eased wi h he
disease condi ion in compa ison o con ols, finding s a is ically
significan di e ences a 8 mon hs o pa ien s wi hou PR
(P≤0.05), and a 12 mon hs o pa ien s ha expe ienced he
PR phase (P<0.01), whose le els we e also highe han hose o
pa ien s a disease onse (P<0.01) (Figu e 3B).
Conce ning memo y T
REG
, hey inc eased in pe cen age
compa ed o he con ol g oup a 8 mon hs o pa ien s wi hou
emission (P<0.01), and a 12 mon hs o pa ien s who expe ienced
PR (P≤0.05). As men ioned abo e, pa ien s wi hou emission a 8
mon hs p esen a highe pe cen age o memo y T
REG
han pa ien s
du ing PR (P≤0.05) (Figu e 3C). Thei absolu e numbe s beha ed
simila ly, inc easing wi h he disease condi ion bo h a 12 mon hs
a e diagnosis o emi e pa ien s (P<0.001) and a 8 mon hs o
non- emi e s (P≤0.05) when compa ed o con ols. Also, hei
numbe s we e highe a 12 mon hs o emi e pa ien s han a
T1D onse (P≤0.05) (Figu e 3D).
As o ac i a ed T
REG
, no di e ences we e ound be ween
pa ien s wi h and wi hou PR (Supplemen al Figu e 6).
A di e en endency on he pe cen age o T
REG
om disease
onse (baseline) o PR was obse ed o 4 child en, who inc eased
his cell subpopula ion in con as o he o he emi e pa ien s,
and as non- emi e pa ien s did (Figu e 3E). Since hose 4
child en in PR p esen he same beha io as he non- emi e s a
8 mon hs, di e ences be ween he wo g oups o emi e
pa ien s we e in es iga ed. In e es ingly, hese 4 child en wi h
inc easing pe cen ages o T
REG
om baseline we e all males, and
hey we e he younges (mean 5.5 s 11.1 yea s, P≤0.05).
Mo eo e , hey p esen ed lowe basal C-pep ide concen a ions
(mean 0.28 s 1.03, P≤0.05) and BMI alues (mean 15.6 s 18.97,
P≤0.05), equi ed lowe doses o insulin (mean 0.28 s 0.44,
P≤0.05), and p esen ed a endency o a highe pe cen age o
HbA1c in compa ison o he o he 7 emi e s wi h dec easing
pe cen ages o T
REG
om baseline (Supplemen al Table 3).
Inc ease in Regula o y B Lymphocy e
Subpopula ions A e One-Yea Follow-Up
o Pa ien s Tha Expe ienced he
PR Phase
Because o he desc ibed ole o B lymphocy es in T1D
pa hogenesis, we nex examined di e en naï e and memo y B
lymphocy e subse s. Figu e 4 shows he ga ing s a egy ollowed
o he an ibody panel o B lymphocy e subpopula ions.
In e es ingly, wo B lymphocy e subse s wi h egula o y
unc ions— ansi ional T1 B lymphocy es and egula o y B
cells (B
REG
)—we e inc eased a 12 mon hs o emi e pa ien s
(Figu e 5). The pe cen age o o al ansi ional B lymphocy es
was subs an ially dec eased a disease onse when compa ed o
he con ol g oup (P≤0.05), and hei le els ended o eco e
wi h ime (Figu e 5A). Wi hin his subpopula ion, ansi ional
T1 B lymphocy es inc eased in pe cen age a 12 mon hs o
pa ien s ha expe ienced he PR phase when compa ed o he
diagnosis (P<0.01), while ansi ional T2 B lymphocy es
dec eased (P<0.01) (Figu es 5B, C). Mo eo e , a his ime-
poin , pa ien s p esen ed a highe T1/T2 a io han pa ien s a
T1D onse (P<0.01) (Figu e 5D).
The ga ing s a egy ollowed o he an ibody panel o B
lymphocy e ma u a ion s ages is depic ed in Supplemen al
Figu e 7. Conce ning he pe cen ages and absolu e coun s o
o al B lymphocy es, naï e B lymphocy es, CD21
−/low
naï e B
lymphocy es, ma u e naï e B lymphocy es, memo y B
lymphocy es—namely, exhaus ed, unswi ched, swi ched, and
IgM memo y B lymphocy es—(Supplemen al Figu es 8, 9)
and plasmablas s (Supplemen al Figu e 10), no di e ences
we e ound be ween pa ien s wi h and wi hou PR.
Inna e Immune Cells A e Al e ed a he
Ini ial S ages o T1D and Du ing he PR
Phase
We ha e p e iously shown he po en ial ha subse s o NK cells
ha e as bioma ke s o T1D p og ession and PR (20). Thus,
changes in neu ophils and di e en subse s o monocy es and
DCs we e in es iga ed. Figu e 6 shows he ga ing s a egy
ollowed o he an ibody panel o inna e cells. Al hough no
significan di e ences we e ound be ween g oups ega ding he
pe cen age o o al monocy es (Figu e 7A), we ound an inc ease
in he pe cen age o classical CD16
−
monocy es du ing he PR
phase in compa ison o disease onse (P≤0.05), and a subsequen
dec ease in he pe cen age o non-classical CD16
+
monocy es
(P≤0.05) (Figu es 7B, C).
The pe cen age o o al DCs inc eased a e 8 mon hs om
diagnosis o non- emi e pa ien s in compa ison o pa ien s a
PR (P≤0.05) and o pa ien s a disease onse (P≤0.05). Those
significan inc eases can be also obse ed 12 mon hs a e
diagnosis o emi e pa ien s (Figu e 7D). When analyzing
he wo main subse s o DCs, he myeloid (mDCs) and he
plasmacy oid (pDCs) ones, no significan di e ences we e ound
be ween g oups ega ding mDCs (Figu e 7E), bu pDCs
inc eased a 12 mon hs o non- emi e pa ien s when
compa ed o diagnosis (P≤0.05) (Figu e 7F).
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254268
AB
D
E
C
FIGURE 3 | Pe iphe al blood T
REG
a e quan i a i ely al e ed a he ini ial s ages o T1D. Pe cen ages (%) and concen a ions (cells/µl) o (A, B) T
REG
and o
(C, D) memo y T
REG
we e de e mined in pe iphe al blood o con ols and pa ien s wi h T1D a di e en ime-poin s. Squa es ep esen con ols (n= 17) (whi e ba ),
and pa ien s a e ep esen ed by ligh g ay do s a disease onse (n= 16) (g ay ba ), whi e do s du ing PR (n= 11) and o emi e pa ien s a 12 mon hs (12 M PR)
(n= 10) (blue ba s), and da k g ay do s o non- emi e pa ien s a 8 mon hs (8 M no PR) (n= 6) and 12 mon hs (12 M no PR) (n= 6) (pink ba s). (E) Rep esen a i e
plo s o he di e ence in he T
REG
pe cen age be ween PR and non-PR (8 M), and changes in his cell popula ion om he disease onse o he PR phase o non-PR
(8 M). Ba g aphs show mean pe cen age o absolu e coun alues. Each symbol ep esen s an indi idual pa ien . Lines link he same pa ien h oughou he ime-
poin s. *P≤0.05, **P<0.01, ***P<0.001 a e mixed e ec s model wi h Tukey’s pos -hoc es o longi udinal da a, K uskal–Wallis wi h Dunn’s pos -hoc es o
compa isons be ween con ol subjec s and he di e en T1D ime-poin s, o 2- ailed Mann–Whi ney es o compa isons be ween wo unpai ed g oups o da a.
P≤0.05 is conside ed significan .
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 8254269
VIF was 1.002 and R
2
was 0.0017 (Supplemen al Table 6).
Consequen ly, mul icollinea i y is no a p oblem in ou da a.
In summa y, a model comp ising he pe cen ages o T
REG
,
DCs, and monocy es all oge he in an index could p edic he PR
phase in child en and adolescen s a T1D diagnosis.
DISCUSSION
The PR phase is s ill a poo ly cha ac e ized s age o T1D na u al
his o y bu is o g ea in e es gi en i s associa ion wi h be e
glycemic con ol and he consequen educ ion in seconda y
complica ions (8). In his s udy, we ha e analyzed up o 52
pe iphe al immune cell subpopula ions and di e en cy okines
in plasma du ing one yea om T1D onse , ocusing mainly on
he s age o PR. Specific al e a ions o his phase ha e been
disco e ed in e ms o he pe cen age o EM T lymphocy es,
T
ERMA
lymphocy es, T
REG
,neu ophils,DCs,B
REG
,and
ansi ional T1 B lymphocy es. In addi ion, we ha e c ea ed a
p edic ion model o PR ha is based on an index ha conside s
he pe cen ages o T
REG
, monocy es, and DCs, and ha could
dis inguish be ween emi e s and non- emi e s a diagnosis.
Despi e needing independen alida ion, hese candida e
immunological bioma ke s o moni o and p edic he PR
co obo a e ha his s age is go e ned by bo h me abolic and
immunological ac o s.
Al hough some s udies in es iga ing he PR phase ha e been
epo ed, only a ew ha e pe o med a longi udinal ollow-up
oge he wi h compa isons be ween emi e and non- emi e
pa ien s a an immunological le el. To he bes o ou knowledge,
and based on he IDAA1c index o define emission, his is he
fi s s udy ha p ospec i ely moni o s immune cell subse s and
cy okines in child en and adolescen s wi h T1D om disease
onse o he fi s yea a e diagnosis, ocusing on he PR phase
AB D
EFG
I
H
JKL
C
FIGURE 9 | The pe cen age o T
REG
, DCs, and monocy es, and he o al daily insulin dose a T1D onse can disc imina e be ween u u e emi e s and non-
emi e s. (A–D) Box-and-whiske plo s showing he pe cen age le els o (A) T
REG
,(B) DCs, and (C) monocy es, and (D) insulin dose a T1D onse sepa a ed by
u u e emi e s (blue boxes) and non- emi e s (pink boxes). Boxes indica e he fi s and hi d qua iles and whiske s ange om minimum o maximum alues. The
ho izon al ba in he box indica es he median. (E–H) ROC cu es plo ing sensi i i y and 1-specifici y o de ec ing child en wi h PR using pe cen ages o (E) T
REG
,
(F) DCs, and (G) monocy es, and (H) insulin dose. The AUC is indica ed, being a measu e o how well a quan i a i e es can dis inguish be ween pa ien s wi h and
wi hou PR. (I–L) Violin plo s showing he equency dis ibu ion o p edic ed p obabili ies o bo h he obse ed PR and non-PR g oups ega ding he pe cen age o
(I) T
REG
,(J) DCs, and (K) monocy es, and (L) insulin dose. Each do ep esen s an indi idual pa ien . Violin plo s show he median ( hick dashed line) and fi s and
hi d qua iles ( hin dashed lines). *P≤0.05, **P<0.01 a e 2- ailed Mann–Whi ney es . P≤0.05 is conside ed significan . N=24–27.
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 82542616
and compa ing be ween emi e s and non- emi e s o find
eliable specific bioma ke s.
CD8
+
T cells a e he p edominan componen o insuli is in
ecen -onse T1D ollowed by mac ophages and CD4
+
T cells
(34,35).Thehe e epo edinc easein hepe cen ageso
pe iphe al blood CD4
+
and CD8
+
T
ERMA
lymphocy es and EM
CD4
+
T lymphocy es a PR could eflec hei lowe mig a ion o
he panc eas, esul ing in educed pe cen ages o pe iphe al
AB
DE
C
FIGURE 10 | An index-based model comp ising he pe cen age o T
REG
, DCs, and monocy es could p edic PR a T1D diagnosis. (A) Spea man’s co ela ion
coe ficien ma ix be ween insulin dose and he pe cen age o T
REG
(n=25),and(B) be ween he pe cen ages o T
REG
, DCs, and monocy es (n= 22) a e shown in he
o m o a hea map o alues (blue; posi i e co ela ion; ed, nega i e co ela ion). (C) S a egy ollowed o c ea e an index comp ising all he independen significan
a iables. F om ROC cu es, he bes cu -o alues we e selec ed o disc imina e be ween he emi e and he non- emi e g oups o he pe cen ageo T
REG
(<8.35),
DCs (>16.45), and monocy es (<14.35), conside ing bo h he sensi i i y and he specifici y wi h 95% CI. An index including he selec ed cu -o ’s alues was c ea ed o
de e mine o each pa ien how many condi ions hey me o en e ing PR on a 0–3 scale (0, no condi ion; 3, all condi ions), being he cu -o s he condi ions ha should
be ulfilled. (D) G aphical ep esen a ion o he AUC o he c ea ed index. (E) Violin plo showing he equency dis ibu ion o p edic ed p obabili ies o bo h he
obse ed PR (n= 16) and non-PR (n= 6) g oups ega ding he index. Each do ep esen s an indi idual pa ien . Violin plo s show he median ( hick dashed line) and
fi s and hi d qua iles ( hin dashed lines). *P≤0.05 a e Spea man’s co ela ion es , ***P<0.001 a e 2- ailed Mann–Whi ney es . P≤0.05 is conside ed significan .
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 82542617
naï e T lymphocy es. Acco ding o hese findings, inc eased
pe cen ages o ci cula ing cy o oxic T lymphocy es posi i e o
IFN-g,T
H
1 lymphocy es, and T
H
17 lymphocy es ha e been
ound du ing he PR phase in compa ison o he disease onse
(21), and also a e he fi s yea om diagnosis o CD4
+
and
CD8
+
T
ERMA
lymphocy es, EM CD4
+
T lymphocy es, and T
H
17
lymphocy es (19). O no e, isle s om pa ien s wi h T1D exp ess
CXCL10, a chemokine in ol ed in au o eac i e T lymphocy e
ec ui men , while in con ols, nei he CXCL10
+
endoc ine cells
no CXCR3
+
lymphocy es we e de ec ed (36). Tha could
pa ially explain he lowe pe cen ages o EM CD8
+
T cells
obse ed a T1D onse in he pe iphe y (37). Also, b-cells om
pa ien s wi h T1D hype exp ess HLA class I, hus inc easing
au oan igen p esen a ion o au o eac i e CD8
+
T cells (38),
which we e ound wi hin he isle s showing an an igen-
expe ienced pheno ype (CD45RA
−
)(39,40). Since he main
media o s o b-cell des uc ion in T1D a e au o eac i e e ec o
CD4
+
and CD8
+
T cells, and supposing ha EM T lymphocy es
a e ac ing less in si u, hei inc ease in he pe iphe y du ing PR
could eflec ana emp a immuno egula ionandb-cell
eco e y. In e es ingly, a ecen longi udinal s udy (24)
desc ibed an associa ion o he PR phase wi h he es o a ion
o he p og ammed cell dea h-1/p og ammed dea h-ligand 1 axis
on T cells, sugges ing a mechanism o immuno egula ion ha
did no occu in non- emi e pa ien s.
On he o he hand, homeos asis be ween T
REG
and e ec o T
lymphocy es is c ucial o he induc ion and main enance o
pe iphe al ole ance. The p ediabe ic phase in he na u al his o y
o T1D is indeed e y he e ogeneous; i can las om mon hs o
yea s, and di e en ac o s influence he ac o p esen ing o e
T1D, like he numbe and i e s o au oan ibodies. E idence
suppo s ha ha ing highe equencies o insulin-specificT
REG
is associa ed wi h a slow p og ession o clinically symp oma ic
T1D (41), bu ha a his ime-poin , T
REG
a e dys unc ional,
hus con ibu ing di ec ly o disease de elopmen [ e iewed in
(42)]. Howe e , he dominance o T
REG
o e e ec o T cells may
con ibu e o PR occu ence (32). In ac , isle -specific CD8
+
T
cells wi h an exhaus ion-like p ofile iden i y pa ien s wi h slow
T1D p og ession a e onse (43). Un il ecen ly, i was gene ally
accep ed ha he o e all equency o pe iphe al blood
CD4
+
FoxP3
+
T
REG
is unal e ed in pa ien s wi h T1D (44–46).
None heless, con adic o y da a on T
REG
ha e been epo ed,
p obably because o he di e en ways ha hese cells can be
iden ified. He e, we ound ha CD4
+
CD25
+
CD127
−/low
and
memo y T
REG
a e dec eased in pe cen age a PR in
compa ison o pa ien s wi hou PR. One possible explana ion
is ha hese cells could eco e hei impai ed unc ion wi h he
apid ec ifica ion o hype glycemia a e T1D onse , being mo e
ac i e in seconda y lymphoid o gans and he a ge issue. Using
he same ma ke s, Fi as e al. (21) ound only a dec ease in T
REG
a e a yea om T1D onse , bu no du ing he PR phase, while
we p e iously ound an inc ease in ac i a ed T
REG
one yea a e
diagnosis (19). O he s udies in es iga ing he associa ion o T
lymphocy es and PR ound ha i s leng h posi i ely co ela es
wi h he high equency o ac i a ed T
REG
(18)and
CD4
+
CD25
+
CD127
hi
Tcells(17) a disease onse .
Fu he mo e, IL-10-dependen egula o y CD4
+
T lymphocy e
pa hways a e in ol ed in long- e m emission o T1D (15), and
isle -specificIL-10
+
immune esponses bu no
CD4
+
CD25
+
FoxP3
+
cells a diagnosis p edic glycemic con ol.
In ac , pe iphe al an igen-specificT
REG
we e diminished du ing
PR in compa ison o diagnosis (22). We ound his end o o al
T
REG
cells in mos o ou emi e pa ien s excep ou . Those
pa ien s p esen ed a simila beha io o non- emi e s, who
p esen ed inc eased pe cen ages o T
REG
cells om disease
onse . In e es ingly, hey a e he younges wi hin he PR g oup.
Since pedia ic pa ien s diagnosed be o e age 7 may ha e a mo e
agg essi e o m o T1D, ha could be ela ed o he obse ed
changes in T
REG
cells (47). In conclusion, u he
cha ac e iza ion o T
REG
subse s in e ms o pheno ype and
unc ion needs o be add essed o dissec hei ole du ing PR.
Inna e immune cells a e c ucial playe s in he de elopmen
and p og ession o T1D and mul iple in e ac ions occu be ween
hem and lymphocy es (48). He e, neu ophils and DCs we e
ound o be al e ed du ing PR. Neu ophils a e p esen in he
insuli is be o e diagnosis, and hey con inue infil a ing he
panc eas as he disease p og esses, ha ing a di ec pa hogenic
ole (49). P e ious esul s showed a educ ion in neu ophil
coun s a diagnosis ha is associa ed wi h a poo endoc ine
panc ea ic unc ion (50,51). He e, we did find a educ ion in
CD16
+
neu ophil absolu e coun s in non- emi e pa ien s bo h
a 8 and 12 mon hs a e he diagnosis when compa ed o
emi e pa ien s. Pe iphe al neu ophils mainly exp ess a
a he a ypical CD16, he FcgRIIIB, which can igge
neu ophil ac i a ion. The possible explana ions o he
dec eased CD16
+
neu ophil a e 1) he g ea e ac i a ion o
apop osis ha would in ol e FcgRIIIB p o eoly ic clea age, 2)
issue de ainmen , o 3) abno mal ma u a ion (51–53). As
TABLE 4 | Simple logis ic eg ession o index as a de e minan o PR in pedia ic pa ien s a T1D onse and i s adjus men o BMI-SDS.
Simple logis ic eg ession
Va iable Coe ficien SE OR [95% CI] |Z| P- alue
C
G es P- alue
D
Index
A
2.525 1.159 12.49 [2.350 o 283.5] 2.18 0.03* 12.75 0.0004***
Mul iple logis ic eg ession
Index
A
2.669 1.335 14.43 [2.371 o 568.1] 1.999 0.05* 12.83 0.0016**
BMI-SDS
C
−0.374 1.303 0.69 [0.043 o 10.69] 0.287 0.77
A
T
REG
(%) + Monocy es (%) + DCs (%) cu -o alues om independen ROC cu es as condi ions o be ulfilled on a 0–3 scale.
C
P- alue om OR;
D
P- alue om G es . BMI, Body Mass
Index; SDS, s anda d de ia ion sco e; SE, s anda d e o . *P ≤0.05, **P ≤0.01, ***P ≤0.001.
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 82542618
hype glycemia is linked o neu ophil dys unc ion, non- emi e s
a e mo e suscep ible o p esen hose impai men s. On he o he
hand, DCs play a pi o al ole in modula ing T cell esponses by
al e ing he balance be ween ole ance and au oimmuni y (54).
We ound ha pa ien s a PR p esen lowe pe cen ages o DCs
han non- emi e pa ien s. P e ious esea ch in pedia ic
pa ien s ound impai ed unc ionali y, pe cen ages, and/o
numbe s in o al DCs, mDCs, and pDCs bo h a T1D onse
and one yea a e diagnosis (55–57). One explana ion could be
he p e iously desc ibed educed p oduc ion o DCs om
monocy es in T1D (58), al hough ou da a on he DC numbe s
do no fi well wi h hose esul s. Also, inflamma ion causes
CCL2 elease om isle s, p omp ing ansloca ion o CCR2
+
DCs
om ci cula ion o inflamed issues, hus causing a educ ion in
DCs coun s and hei CCR2 exp ession in pe iphe al blood (56).
Since he amelio a ion o hype glycemia could con ibu e o he
eco e y o he immunosupp essi e p ope ies o DCs du ing he
PR phase (59), ole ogenic DCs exp essing CCR2 could be mo e
ac i e in he a ge issue, diminishing in pe iphe al blood and
p omp ing T
REG
esponses.
In addi ion, a e 12 mon hs o ollow-up, only pa ien s ha
expe ienced PR showed inc eased le els o B
REG
and ansi ional
T1 B lymphocy es. Acco ding o ou esul s, o he s udies in
new-onse T1D ha e no ound al e a ions in o he B cell subse s
(37,60), while ansi ional B cells and B
REG
inc eased in pedia ic
pa ien s one yea a e diagnosis (19). Bo h B
REG
and ansi ional
B lymphocy es ha e immuno egula o y p ope ies and can
inhibi e ec o T cell p oli e a ion (61,62). Some esul s
sugges ha B cell subse s could play a ole in T1D
pa hogenesis, o ins ance, bo h he pe cen age o IL-10
+
B
REG
and IL-10
+
imma u e ansi ional B cells we e significan ly lowe
in pa ien s wi h T1D a diagnosis han in con ols and pa ien s
wi h wo se glycemic con ol (63,64). Rega ding ansi ional B
cells, hese a e classified in T1 and T2 subse s, ha ing T1 cells
g ea e immunosupp essi e p ope ies. The e o e, he he e
epo ed highe a io o T1/T2 cells and he inc eased coun s
o B
REG
a e a yea o ollow-up o emi e pa ien s could
eflec an immuno egula o y a emp .
Cy okines o ches a e mul iple in e ac ions be ween bcells
and immune cells. He e, none o he analyzed cy okines showed
significan di e ences be ween emi e s and non- emi e s,
which would limi hei use as bioma ke s o emission o T1D
p og ession. Howe e , we ound inc eased le els o IL-17A, a
ele an cy okine in T1D (65), a disease onse , and a end o
educe his cy okine in emi e pa ien s. IL-17A exp ession is
up egula ed in he panc eas o bo h humans and animal models
(44,66), and among o he e ec s, i ec ui s and ac i a es
neu ophils (67). Because IL-23 and/o TGF-bplus IL-6 d i e
he p oduc ion o IL-17 by T cells, he he e epo ed IL-17A
inc ease oge he wi h he highe le els o TGF-band IL-6 could
eflec he inflamma o y s a e a diagnosis, which is less e iden
a PR. In ac , we ound a posi i e co ela ion be ween IL-6 and
IL-17A a T1D onse , whe eas his co ela ion was nega i e in
con ols (da a no shown). In a p e ious non-longi udinal s udy,
low TGF-ble els we e a ea u e o PR (19), which has no been
confi med in his longi udinal s udy. While none o he analyzed
cy okines we e p edic i e o PR, in a p ospec i e s udy o T1D,
lowe le elso IL-10,IFN-g, and IL-1R1 a diagnosis we e
associa ed wi h emission (26). In summa y, he use o
cy okines as T1D p og ession ma ke s does no seem o ha e
enough powe o co ec ly dis inguish PR.
Because he e ficacy o immuno he apies depends on he ime
o in e en ion, ma hema ical models o p edic ing disease
p og ession (68) and PR a e impo an ools o imp o e
he apeu ic s a egies. Rega ding me abolism, p e ious s udies
ha e shown associa ions be ween me abolic and clinical
pa ame e s and he PR phase. In ou bi a ia e analysis, only
he lowe insulin dose a T1D onse could p edic emission.
Al hough no significan , and acco ding o p e ious da a, we
ound ha pa ien s wi h highe BMI and olde age a diagnosis
a e mo e p one o expe ience emission (69). In gene al, child en
expe ience emission o a highe ex end han adul s, and wi hin
he fi s g oup, he p obabili y o emaining in emission is
g ea e as he onse age inc eased (70). Di e en eg ession
analyses showed ha highe pH and bica bona e le els, highe
BMI, male sex, and lowe HbA1c, insulin dose, and numbe s
o isle an ibodies a T1D onse a e p edic o s o emission
(13,14,70–72). Howe e , he p edic ion o emission using
immunological da a is a he sca ce. Unlike IFN-gconcen a ion,
ele a ed le els o IL-10 and IL-6 in se um a e posi i ely
associa ed wi h emission (22,23), and he absence o IL-4,
TNF-a, IL-10, and IL-13 de ec ion is posi i ely co ela ed wi h
i s leng h (21). Also, CD4
+
CD45RO
+
T cells, ac i a ed T
REG
,
CD4
+
CD25
+
CD127
hi
T cells, and apop o ic T
REG
a e epo edly
associa ed wi h emission (17,18,73). He e, we ound ha he
pe cen ages o T
REG
, monocy es, and DCs a T1D onse a e
independen p edic o s o he PR phase. T
REG
we e also
posi i ely co ela ed wi h he insulin dose, highligh ing he
c ucial ole o immunome abolism in e ac ions du ing T1D
and he mechanisms ec i ying glucose oxici y in he p ocess
o b-cell p o ec ion. The bi a ia e analysis o he gene a ed index,
which includes he cell pe cen ages, showed an e en highe
abili y o dis inguish emi e s om non- emi e s. When he
index was adjus ed o possible con ounde s, only i emained a
significan p edic o o PR. In summa y, we p opose a no el
immune-based p edic i e model o emission, al hough i mus
be u he alida ed in a la ge coho o pa ien s.
We a e awa e o he limi a ions o he p esen ed s udy. Fi s ,
he numbe o indi iduals s udied lowe s he s a is ical powe ;
howe e , such da a a e e y ha d o ob ain. Ano he weak poin
o ou coho is he wide ange o ages ( om 4 o 18) and he
a iabili y ha his en ails ega ding he physiological changes
ha he subjec s unde go (i.e., pube y). Whe eas a ia ions in
he le els o immune cell subpopula ions o e one yea in heal hy
pedia ic o adul subjec s a e sub le o inexis en (74,75),
changes a e obse ed wi hin longe acking pe iods (76). In
ha sense, we pe o med co ela ions be ween age and he
pe cen age o absolu e coun s o he di e en analyzed
immune cell subse s bo h in con ols and pa ien s a T1D
onse . We obse ed ha he le els o ansi ional B cells and
CD8
+
T
EMRA
cells a e nega i ely co ela ed wi h age and ha he
le els o EM and CM CD4
+
T cells a e posi i ely co ela ed (da a
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 82542619
no shown). Since ou longi udinal da a showed an inc ease in
ansi ional B cells a e one yea o ollow-up and a dec ease in
he pe cen age o EM CD4
+
T cells, hese changes a e likely o be
a consequence o T1D p og ession. Al hough he usage o
pe iphe al blood as a sou ce o bioma ke s is a non-in asi e
echnique, immune cells a e igh ly egula ed by hei gene a ion
in p ima y lymphoid o gans and hei mig a ion o issues, hei
changes in he pe iphe y being di ficul o in e p e . The analysis
o he a ge o gan and u he s udies on he unc ionali y o
immune cells (i.e., cy okine p oduc ion)—including an igen-
specific T cells—a e needed o co ela e changes in he
pe iphe y wi h he e en s occu ing in he panc eas. Mo eo e ,
a la ge sample size in u u e s udies is needed o alida e he
he e p oposed bioma ke s o he PR phase. Since limi ed
amoun o blood was ob ained om pedia ic pa ien s,
au oan ibodies o insulin (IAA) ha e no been explo ed.
Howe e , due o i s b-cell specifici y, he baseline i e o IAA
could be o in e es o he s udy o he PR phase. S ill ocusing
on his s age, we a e no e alua ing i s leng h, which could be
ela ed o he pe sis ence and ac i i y o ce ain immune cells.
The s eng hs o he s udy include he longi udinal pic u e o
T1D ea ly s ages, he cha ac e iza ion o he PR phase e sus
non- emission by a wide ange o immune subpopula ions and
cy okines, and he use o IDAA1c o ≤9 odefine PR, an index
ha includes glycemic con ol and insulin doses, ha co ela es
wi h C-pep ide le els, and ha has been alida ed in a la ge
coho o young pa ien s wi h T1D (77).
In conclusion, he PR phase is no only accompanied by
changes in di e en me abolic pa ame e s, bu also by changes in
immune cells and molecules. These al e a ions could be po en ial
moni o ing and p edic i e bioma ke s use ul o pa ien
s a ifica ion in clinical ials and he iden ifica ion o pa ien s
wi h be e glycemic con ol ha will enable a mo e pe sonalized
he apeu ic managemen .
DATA AVAILABILITY STATEMENT
The o iginal con ibu ions p esen ed in he s udy a e included in
he a icle/Supplemen a y Ma e ial. Fu he inqui ies can be
di ec ed o he co esponding au ho .
ETHICS STATEMENT
The s udies in ol ing human pa icipan s we e e iewed and
app o ed by he Commi ee on he E hics o Resea ch o he
Ge mans T ias i Pujol Uni e si y Hospi al and Pa c Taulı
Uni e si y Hospi al. W i en in o med consen o pa icipa e
in his s udy was p o ided by he pa icipan s’legal gua dian/
nex o kin.
AUTHOR CONTRIBUTIONS
LGM, DPB, SRF, and MVP designed he expe imen s. FV, MM,
AV, JP, RC, LC, and JB selec ed he pa ien s, ob ained he
samples, and/o de e mined au oan ibodies. LGM and DPB
pe o med he expe imen s. LGM, DPB, and JMCA analyzed
he da a. LGM and MVP w o e he manusc ip . All au ho s lis ed
ha e made a subs an ial, di ec , and in ellec ual con ibu ion o
he wo k and app o ed i o publica ion.
FUNDING
Funding o his s udy was p o ided by he Spanish Go e nmen
(FIS PI18/00436) co-financed wi h he Eu opean Regional
De elopmen unds (FEDER), and by Diabe esCe o
Founda ion. LGM is suppo ed by he Gene ali a de
Ca alunya (PERIS PIF-Salu G an No. SLT017/20/000049).
This wo k has been suppo ed by posi i e discussion h ough
Consolida ed Resea ch G oup #2017 SGR 103, AGAUR,
Gene ali a de Ca alunya.
ACKNOWLEDGMENTS
We a e g a e ul o he Lilly Founda ion o sponso ing he awa d
gi en o his wo k du ing he 43 d Cong ess o he Spanish
Socie y o Pedia ic Endoc inology (2021). Special hanks o Ms.
N. Real om he Pedia ics Dep . o he HUGTiP o ob aining
he samples. We app ecia e he ad ice om D . E. Ma ı
nez-
Cace es,D .A.Tenien e,andMs.B.Qui an om he
Immunology Dep . (HUGTiP). We a e g a e ul o M . M.
Fe nandez and G. Requena om he Flow Cy ome y Pla o m
(IGTP) o hei suppo .
SUPPLEMENTARY MATERIAL
The Supplemen a y Ma e ial o his a icle can be ound online
a : h ps://www. on ie sin.o g/a icles/10.3389/fimmu.2022.
825426/ ull#supplemen a y-ma e ial
REFERENCES
1. Ka sa ou A, Gudbjö nsdo i S, Rawshani A, Dabelea D, Boni acio E,
Ande son BJ, e al. Type 1 Diabe es Melli us. Na Re Dis P im (2017)
3:17016. doi: 10.1038/n dp.2017.16
2. Pa e son CC, Ha ju salo V, Rosenbaue J, Neu A, Cinek O, Sk i a haug T,
e al. T ends and Cyclical Va ia ion in he Incidence o Childhood Type 1
Diabe es in 26 Eu opean Cen es in he 25 Yea Pe iod 1989–2013: A
Mul icen e P ospec i e Regis a ion S udy. Diabe ologia (2019) 62(3):408–
17. doi: 10.1007/s00125-018-4763-3
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 82542620
3. Lehuen A, Diana J, Zaccone P, Cooke A. Immune Cell C oss alk in Type 1
Diabe es. Na Re Immunol (2010) 10(7):501–13. doi: 10.1038/n i2787
4. A kinson MA, Roep BO, Posgai A, Wheele DCS, Peakman M. The Challenge
o Modula ing b-Cell Au oimmuni y in Type 1 Diabe es. Lance Diabe es
Endoc inol (2019) 7(1):52–64. doi: 10.1016/S2213-8587(18)30112-8
5. Roep BO, Wheele DCS, Peakman M. An igen-Based Immune Modula ion
The apy o Type 1 Diabe es: The E a o P ecision Medicine. Lance Diabe es
Endoc inol (2019) 7(1):65–74. doi: 10.1016/S2213-8587(18)30109-8
6. Culina S, Mallone R. Immune Bioma ke s in Immuno he apeu ic T ials o
Type 1 Diabe es: Cui P odes ? Diabe es Me ab (2012) 38(5):379–85.
doi: 10.1016/j.diabe .2012.05.005
7. on He a h M, Peakman M, Roep B. P og ess in Immune-Based The apies
o Type 1 Diabe es. Clin Exp Immunol (2013) 172(2):186–202. doi: 10.1111/
cei.12085
8. Fonolleda M, Mu illo M, Vazquez F, Bel J, Vi es-Pi M. Remission Phase in
Paedia ic Type 1 Diabe es: New Unde s anding and Eme ging Bioma ke s.
Ho m Res Paedia (2017) 88(5):307–15. doi: 10.1159/000479030
9. Abdul-Rasoul M, Habib H, Al-Khouly M. “The Honeymoon Phase”in
Child en Wi h Type 1 Diabe es Melli us: F equency, Du a ion, and
Influen ial Fac o s. Pedia Diabe es (2006) 7(2):101–7. doi: 10.1111/j.1399-
543X.2006.00155.x
10. Mu illo M, Fonolleda M, Bosch L, Rod ı
guez-Fe nandez S, Vazquez F, Bel J,
e al. Sus ained Spon aneous Pa ial Remission in a Pedia ic Pa ien Wi h
Type 1 Diabe es. J Clin T ansl Endoc inol Case Rep (2017) 6:11–3.
doi: 10.1016/j.jec .2017.09.001
11. Ka ges B, Du ino ic-Bello I, Heinze E, Boehm BO, Deba in K-M, Ka ges W.
Comple e Long-Te m Reco e y o -Cell Func ion in Au oimmune Type 1
Diabe es A e Insulin T ea men . Diabe es Ca e (2004) 27(5):1207–8.
doi: 10.2337/diaca e.27.5.1207
12. Zhong T, Tang R, Gong S, Li J, Li X, Zhou Z. The Remission Phase in Type 1
Diabe es: Changing Epidemiology, Defini ions, and Eme ging Immuno-
Me abolic Mechanisms. Diabe es Me ab Res Re (2020) 36(2):e3207.
doi: 10.1002/dm .3207
13. Ma ino KR, Lundbe g RL, Jas o ia A, Ma anda LS, Thompson MJ, Ba on BA,
e al. A P edic i e Model o Lack o Pa ial Clinical Remission in New-Onse
Pedia ic Type 1 Diabe es. PloS One (2017) 12(5):e0176860. doi: 10.1371/
jou nal.pone.0176860
14. Wong TWC, Wong MYS, Bu WMB. Fea u es o Pa ial Remission in
Child en Wi h Type 1 Diabe es Using he Insulin Dose-Adjus ed A1c
Defini ion and Risk Fac o s Associa ed Wi h Non emission. Ann Pedia
Endoc inol Me ab (2021) 26(2):118–25. doi: 10.6065/apem.2040202.101
15. Ka ges B, Du ino ic-BelloI, Heinze E, Deba in K-M, Boehm B, Ka ges W.
Immunological Mechanisms Associa ed Wi h Long-Te m Remission o
Human Type 1 Diabe es. Diabe es Me ab Res Re (2006) 22(3):184–9.
doi: 10.1002/dm .600
16. Tang R, Zhong T, Wu C, Zhou Z, Li X. The Remission Phase in Type 1
Diabe es: Role o Hype glycemia Rec ifica ion in Immune Modula ion. F on
Endoc inol (Lausanne) (2019) 10:824. doi: 10.3389/ endo.2019.00824
17. Na sale A, Lam B, Moya R, Lu T, Mandelli A, Go uzzo I, e al. CD4+CD25
+CD127hi Cell F equency P edic s Disease P og ession in Type 1 Diabe es.
JCI Insigh (2021) 6(2):e136114. doi: 10.1172/jci.insigh .136114
18. Moya R, Robe son HK, Payne D, Na sale A, Koziol J, Da ies JD. A Pilo
S udy Showing Associa ions Be ween F equency o CD4+ Memo y Cell
Subse s a Diagnosis and Du a ion o Pa ial Remission in Type 1 Diabe es.
Clin Immunol (2016) 166–167:72–80. doi: 10.1016/j.clim.2016.04.012
19. Villalba A, Fonolleda M, Mu illo M, Rod iguez-Fe nandez S, Ampudia R-M,
Pe na-Ba ull D, e al. Pa ial Remission and Ea ly S ages o Pedia ic Type 1
Diabe es Display Immuno egula o y Changes. A Pilo S udy. T ansl Res
(2019) 210:8–25. doi: 10.1016/j. sl.2019.03.002
20. Gomez-Muñoz L, Pe na-Ba ull D, Villalba A, Rod iguez-Fe nandez S,
Ampudia R-M, Tenien e-Se a A, e al. NK Cell Subse s Changes in Pa ial
Remission and Ea ly S ages o Pedia ic Type 1 Diabe es. F on Immunol
(2021) 11:611522. doi: 10.3389/fimmu.2020.611522
21. Fi as AL, Ma ins C, Bo ego LM, Lopes L, Jö ns A, Lenzen S, e al. Immune
Cell and Cy okine Pa e ns in Child en Wi h Type 1 Diabe es Melli us
Unde going a Remission Phase: A Longi udinal S udy. Pedia Diabe es
(2018) 19(5):963–71. doi: 10.1111/pedi.12671
22. Sanda S, Roep BO, on He a h M. Isle An igen Specific IL-10+ Immune
Responses Bu No CD4+CD25+FoxP3+ Cells a Diagnosis P edic Glycemic
Con ol in Type 1 Diabe es. Clin Immunol (2008) 127(2):138–43.
doi: 10.1016/j.clim.2007.12.003
23. Pflege C, Mo ensen HB, Hansen L, He de C, Roep BO, Hoey H, e al.
Associa ion o IL-1 a and Adiponec in Wi h C-Pep ide and Remission in
Pa ien s Wi h Type 1 Diabe es. Diabe es (2008) 57(4):929–37. doi: 10.2337/
db07-1697
24. Li X, Zhong T, Tang R, Wu C, Xie Y, Liu F, e al. PD-1 and PD-L1 Exp ession
in Pe iphe al CD4/CD8+ T Cells Is Res o ed in he Pa ial Remission Phase in
Type 1 Diabe es. JClinEndoc inolMe ab(2020) 105(6):1947–56.
doi: 10.1210/clinem/dgaa130
25. Alizadeh BZ, Hanifi-Moghaddam P, Ee ligh P, an de Slik AR, Kolb H,
Kha agji singh AV, e al. Associa ion o In e e on-gand In e leukin 10
Geno ypes and Se um Le els Wi h Pa ial Clinical Remission in Type 1
Diabe es. Clin Exp Immunol (2006) 145(3):480–4. doi: 10.1111/j.1365-
2249.2006.03172.x
26. Schloo NC, Hanifi-Moghaddam P, Aabenhus-Ande sen N, Alizadeh BZ,
Saha MT, Knip M, e al. Associa ion o Immune Media o s a Diagnosis o
Type 1 Diabe es Wi h La e Clinical Remission. Diabe es Med (2007) 24
(5):512–20. doi: 10.1111/j.1464-5491.2007.02096.x
27. Kaas A, Pflege C, Hansen L, Buscha d K, Schloo NC, Roep BO, e al.
Associa ion o Adiponec in, In e leukin (IL)-1 a, Inducible P o ein 10, IL-6
and Numbe o Isle Au oan ibodies Wi h P og ession Pa e ns o Type 1
Diabe es he Fi s Yea A e Diagnosis. Clin Exp Immunol (2010) 161(3):444–
52. doi: 10.1111/j.1365-2249.2010.04193.x
28. ADA. 2. Classifica ion and Diagnosis o Diabe es: S anda ds o Medical Ca e
in Diabe es—2018. Diabe es Ca e (2018) 41:S13–27. doi: 10.2337/dc18-S002
29. Ca ascosa Lezcano A, Fe nandez Ga cı
a JM, Fe nandez Ramos C, Fe andez
LongasA,Lo
pez-Sigue o JP, Sanchez Gonzalez E, e al. Es udio T ans e sal
Español De C ecimien o 2008. Pa e II: Valo es De Talla, Peso E Indice De
Masa Co po al Desde El Nacimien o a La Talla Adul a. Pedia ı
a(2008) 68
(6):552–69. doi: 10.1157/13123287
30. Mo ensen HB, Hougaa d P, Swi P, Hansen L, Holl RW, Hoey H, e al. New
Defini ion o he Pa ial Remission Pe iod in Child en and Adolescen s Wi h
Type 1 Diabe es. Diabe es Ca e (2009) 32(8):1384–90. doi: 10.2337/dc08-1987
31. Robb MA, McInnes PM, Cali RM. Bioma ke s and Su oga e Endpoin s:
De eloping Common Te minology and Defini ions. JAMA (2016) 315
(11):1107. doi: 10.1001/jama.2016.2240
32. Jabe i-Dou aki M, Pie opaolo M, Khad a A. Con inuum Model o T-Cell
A idi y: Unde s anding Au o eac i e and Regula o y T-Cell Responses in
Type 1 Diabe es. J Theo Biol (2015) 383:93–105. doi: 10.1016/
j.j bi.2015.07.032
33. Pyziak A, Zmyslowska A, Bobe K, Malachowska B, Fendle W, Wyka K, e al.
Ma ke s Influencing he P esence o Pa ial Clinical Remission in Pa ien s
Wi h Newly Diagnosed Type 1 Diabe es. J Pedia Endoc inol Me ab (2017) 30
(11):1147–53. doi: 10.1515/jpem-2017-0100
34. Nigi L, Macco a C, Do a F, Sebas iani G. F om Immunohis ological o
Ana omical Al e a ions o Human Panc eas in Type 1 Diabe es: New
Concep s on he S age. Diabe es Me ab Res Re (2020) 36(4):e3264.
doi: 10.1002/dm .3264
35. Planas R, Ca illo J, Sanchez A, Ruiz de Villa MC, Nuñez F, Ve dague J, e al.
Gene Exp ession P ofiles o he Human Panc eas and Pu ified Isle s in Type
1 Diabe es: New Findings a Clinical Onse and in Long-S anding Diabe es.
Clin Exp Immunol (2010) 159(1):23–44. doi: 10.1111/j.1365-
2249.2009.04053.x
36. Nigi L, B usco N, G ieco GE, Lica a G, K og old L, Ma selli L, e al. Panc ea ic
Alpha-Cells Con ibu e Toge he Wi h Be a-Cells o CXCL10 Exp ession in
Type 1 Diabe es. F on Endoc inol (Lausanne) (2020) 11:630. doi: 10.3389/
endo.2020.00630
37. O as A, Pee A, Giese T, Tillmann V. Uibo R. A S udy o 51 Sub ypes o
Pe iphe al Blood Immune Cells in Newly Diagnosed Young Type 1 Diabe es
Pa ien s. Clin Exp Immunol (2019) 198(1):57–70. doi: 10.1111/cei.13332
38. Richa dson SJ, Rod iguez-Cal o T, Ge ling IC, Ma hews CE, Kaddis JS,
Russell MA, e al. Isle Cell Hype exp ession o HLA Class I An igens: A
Defining Fea u e in Type 1 Diabe es. Diabe ologia (2016) 59(11):2448–58.
doi: 10.1007/s00125-016-4067-4
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 82542621
39. Coppie e s KT, Do a F, Ami ian N, Campbell PD, Kay TWH, A kinson MA,
e al. Demons a ion o Isle -Au o eac i e CD8 T Cells in Insuli ic Lesions
F om Recen Onse and Long-Te m Type 1 Diabe es Pa ien s. J Exp Med
(2012) 209(1):51–60. doi: 10.1084/jem.20111187
40. Gonzalez-Duque S, Azou y ME, Colli ML, A onso G, Tu a sinze J-V, Nigi L,
e al. Con en ional and Neo-An igenic Pep ides P esen ed by bCells A e
Ta ge ed by Ci cula ing Naï e CD8+ T Cells in Type 1 Diabe ic and Heal hy
Dono s. Cell Me ab (2018) 28(6):946–960.e6. doi: 10.1016/j.cme .2018.07.007
41. Se I, Fü s RW, Achenbach P, Sche m MG, Gökmen F, Haup F, e al. Type 1
Diabe es Vaccine Candida es P omo e Human Foxp3+ T eg Induc ion in
Humanized Mice. Na Commun (2016) 7(1):10991. doi: 10.1038/ncomms10991
42. Hull CM, Peakman M, T ee TIM. Regula o y T Cell Dys unc ion in Type 1
Diabe es: Wha ’s B oken and How Can We Fix i ? Diabe ologia (2017) 60
(10):1839–50. doi: 10.1007/s00125-017-4377-1
43. Wiedeman AE, Mui VS, Rosasco MG, DeBe g HA, P esnell S, Haas B, e al.
Au o eac i e CD8+ T Cell Exhaus ion Dis inguishes Subjec s Wi h Slow Type
1 Diabe es P og ession. J Clin In es (2020) 130(1):480–90. doi: 10.1172/
JCI126595
44. Fe a o A, Socci C, S abilini A, Valle A, Mon i P, Piemon i L, e al. Expansion
o Th17 Cells and Func ional De ec s in T Regula o y Cells A e Key Fea u es
o he Panc ea ic Lymph Nodes in Pa ien s Wi h Type 1 Diabe es. Diabe es
(2011) 60(11):2903–13. doi: 10.2337/db11-0090
45. Hama i S, Ki eskoski T, Glumo V, Kulmala P, Simell O, Knip M, e al.
Analyses o Regula o y CD4+ CD25+ FOXP3+ T Cells and Obse a ions
F om Pe iphe al T Cell Subpopula ion Ma ke s Du ing he De elopmen o
Type 1 Diabe es in Child en. Scand J Immunol (2016) 83(4):279–87.
doi: 10.1111/sji.12418
46. B usko T, Wasse all C, McG ail K, Scha z R, Viene HL, Scha z D, e al. No
Al e a ions in he F equency o FOXP3+ Regula o y T-Cells in Type 1
Diabe es. Diabe es (2007) 56(3):604–12. doi: 10.2337/db06-1248
47. Lee e P, Willcox A, K og old L, Dahl-Jø gensen K, Foulis AK, Richa dson SJ,
e al. Di e en ial Insuli ic P ofiles De e mine he Ex en o b-Cell Des uc ion
and he Age a Onse o Type 1 Diabe es. Diabe es (2016) 65(5):1362–9.
doi: 10.2337/db15-1615
48. Diana J, Gahza ian L, Simoni Y, Lehuen A. Inna e Immuni y in Type 1
Diabe es. Disco Med (2011) 11(61):513–20.
49. Huang J, Xiao Y, Xu A, Zhou Z. Neu ophils in Type 1 Diabe es. J Diabe es
In es ig (2016) 7(5):652–63. doi: 10.1111/jdi.12469
50. Qin J, Fu S, Speake C, G eenbaum CJ, Odega d JM. NETosis-Associa ed Se um
Bioma ke s A e Reduced in Type 1 Diabe es in Associa ion Wi h Neu ophil
Coun . Clin Exp Immunol (2016) 184(3):318–22. doi: 10.1111/cei.12783
51. Vecchio F, Lo Buono N, S abilini A, Nigi L, Du o MJ, Geye S, e al.
Abno mal Neu ophil Signa u e in he Blood and Panc eas o
P esymp oma ic and Symp oma ic Type 1 Diabe es. JCI Insigh (2018) 3
(18):e122146. doi: 10.1172/jci.insigh .122146
52. Wang Y, Jönsson F. Exp ession, Role, and Regula ion o Neu ophil Fcg
Recep o s. F on Immunol (2019) 10:1958. doi: 10.3389/fimmu.2019.01958
53. Sil es e-Roig C, F idlende ZG, Glogaue M, Scapini P. Neu ophil Di e si y
in Heal h and Disease. T ends Immunol (2019) 40(7):565–83. doi: 10.1016/
j.i .2019.04.012
54. Audige C, Rahman MJ, Yun TJ, Ta bell KV, Lesage S. The Impo ance o
Dend i ic Cells in Main aining Immune Tole ance. J Immunol (2017) 198
(6):2223–31. doi: 10.4049/jimmunol.1601629
55. Rod iguez-Fe nandez S, Mu illo M, Villalba A, Pe na-Ba ull D, Cano-Sa abia
M, Gomez-Muñoz L, e al. Impai ed Phagocy osis in Dend i ic Cells F om
Pedia ic Pa ien s Wi h Type 1 Diabe es Does No Hampe Thei Tole ogenic
Po en ial. F on Immunol (2019) 10:2811. doi: 10.3389/fimmu.2019.02811
56. Nieminen JK, Vakkila J, Salo HM, Eks om N, Ha konen T, Ilonen J, e al.
Al e ed Pheno ype o Pe iphe al Blood Dend i ic Cells in Pedia ic Type 1
Diabe es. Diabe es Ca e (2012) 35(11):2303–10. doi: 10.2337/dc11-2460
57. Klocpe k A, Pe uzelko a L, Pa liko a M, Ra aj M, Kayse o a J, P uho a S,
e al. Changes in Inna e and Adap i e Immuni y O e he Fi s Yea A e he
Onse o Type 1 Diabe es. Ac a Diabe ol (2020) 57(3):297–307. doi: 10.1007/
s00592-019-01427-1
58. Jansen A, an Hagen M, D exhage HA. De ec i e Ma u a ion and Func ion o
An igen-P esen ing Cells in Type 1 Diabe es. Lance (1995) 345(8948):491–2.
doi: 10.1016/S0140-6736(95)90586-3
59. Thomas AM, Dong Y, Beskid NM, Ga cı
a AJ, Adams AB, Babensee JE. B ie
Exposu e o Hype glycemia Ac i a es Dend i ic Cells In Vi o and In Vi o.
J Cell Physiol (2020) 235(6):5120–9. doi: 10.1002/jcp.29380
60. Thompson WS, Pekalski ML, Simons HZ, Smy h DJ, Cas o-Dopico X, Guo
H, e al. Mul i-Pa ame ic Flow Cy ome ic and Gene ic In es iga ion o he
Pe iphe al B-Cell Compa men in Human Type 1 Diabe es. Clin Exp
Immunol (2014) 177(3):571–85. doi: 10.1111/cei.12362
61. Ca alan D, Mansilla MA, Fe ie A, So o L, Oleinika K, Aguillon JC, e al.
Immunosupp essi e Mechanisms o Regula o y B Cells. F on Immunol
(2021) 12:611795. doi: 10.3389/fimmu.2021.611795
62. Simon Q, Pe s J-O, Co nec D, Le Po ie L, Mageed RA, Hillion S. In-Dep h
Cha ac e iza ion o CD24 High CD38 High T ansi ional Human B Cells
Re eals Di e en Regula o y P ofiles. J Alle gy Clin Immunol (2016) 137
(5):1577–1584.e10. doi: 10.1016/j.jaci.2015.09.014
63. El-Mokh a MA, Elshe biny NM, Sayed D, Raa a DM, Aska E, Hussein A,
e al. Al e ed Regula o y B Cell Subse s in Child en Wi h Type 1 Diabe es
Melli us. J Immunol Res (2020) 2020:8935694. doi: 10.1155/2020/8935694
64. Wang Y, Qin Y, Wang X, Zhang L, Wang J, Xu X, e al. Dec ease in he
P opo ion o CD24 Hi CD38 Hi B Cells and Impai men o Thei Regula o y
Capaci y in Type 1 Diabe es Pa ien s. Clin Exp Immunol (2020) 200(1):22–32.
doi: 10.1111/cei.13408
65. A i S, Moo e F, Ma ks K, Bouckenooghe T, Dayan CM, Planas R, e al.
Pe iphe al and Isle In e leukin-17 Pa hway Ac i a ion Cha ac e izes Human
Au oimmune Diabe es and P omo es Cy okine-Media ed -Cell Dea h.
Diabe es (2011) 60(8):2112–9. doi: 10.2337/db10-1643
66. Vukkadapu SS, Belli JM, Ishii K, Jegga AG, Hu on JJ, A onow BJ, e al.
Dynamic In e ac ion Be ween T Cell-Media ed b-Cell Damage and b-Cell
Repai in he Run Up o Au oimmune Diabe es o he NOD Mouse. Physiol
Genomics (2005) 21(2):201–11. doi: 10.1152/physiolgenomics.00173.2004
67. Pelle ie M, Maggi L, Michele i A, Lazze i E, Tamassia N, Cos an ini C, e al.
E idence o a C oss-Talk Be ween Human Neu ophils and Th17 Cells. Blood
(2010) 115(2):335–43. doi: 10.1182/blood-2009-04-216085
68. Jabe i-Dou aki M, Pie opaolo M, Khad a A. P edic i e Models o Type 1
Diabe es P og ession: Unde s anding T-Cell Cycles and Thei Implica ions on
Au oan ibody Release. PloS One (2014) 9(4):e93326. doi: 10.1371/
jou nal.pone.0093326
69. Passanisi S, Salzano G, Gasba o A, U zì B anca i V, Mondio M, Pajno GB,
e al. Influence o Age on Pa ial Clinical Remission Among Child en Wi h
Newly Diagnosed Type 1 Diabe es. In J En i on Res Public Heal h (2020) 17
(13):4801. doi: 10.1515/jpem-2017-0100
70. Zhong T, Tang R, Xie Y, Liu F, Li X, Zhou Z. F equency, Clinical
Cha ac e is ics, and De e minan s o Pa ial Remission in Type 1 Diabe es:
Di e en Pa e ns in Child en and Adul s. J Diabe es (2020) 12(10):761–8.
doi: 10.1111/1753-0407.13044
71. Chobo A, S ompo J, Szyda K, Sokołowska M, Deja G, Polanska J, e al.
Remission Phase in Child en Diagnosed Wi h Type 1 Diabe es in Yea s 2012
o 2013 in Silesia, Poland: An Obse a ional S udy. Pedia Diabe es (2019) 20
(3):286–92. doi: 10.1111/pedi.12824
72. Nagl K, He mann JM, Plampe M, Sch öde C, Dos A, Ko donou i O, e al.
Fac o s Con ibu ing o Pa ial Remission in Type 1 Diabe es: Analysis Based
on he Insulin Dose-Adjus ed HbA1c in 3657 Child en and Adolescen s F om
Ge many and Aus ia. Pedia Diabe es (2017) 18(6):428–34. doi: 10.1111/
pedi.12413
73. Glisic-Milosa lje ic S, Wang T, Koppen M, K ame J, Ehlenbach S, Waukau J,
e al. Dynamic Changes in CD4+ CD25+ High T Cell Apop osis A e he
Diagnosis o Type 1 Diabe es. Clin Exp Immunol (2007) 150(1):75–82.
doi: 10.1111/j.1365-2249.2007.03475.x
74. Ga cia-P a M, A
l a ez-Sie a D, Aguilo-Cucu ull A, Salgado-Pe and esS,
B iongos-Sebas ian S, F anco-Ja a a C, e al. Ex ended Immunopheno yping
Re e ence Values in a Heal hy Pedia ic Popula ion. Cy om Pa B Clin Cy om
(2019) 96(3):223–33. doi: 10.1002/cy o.b.21728
75. Alpe A, Pickman Y, Leipold M, Rosenbe g-Hasson Y, Ji X, Gaujoux R, e al.
A Clinically Meaning ul Me ic o Immune Age De i ed F om High-
Dimensional Longi udinal Moni o ing. Na Med (2019) 25(3):487–95.
doi: 10.1038/s41591-019-0381-y
76. Shea e WT, Rosenbla HM, Gelman RS, Oyomopi o R, Plaege S, S iehm ER,
e al. Lymphocy e Subse s in Heal hy Child en F om Bi h Th ough 18 Yea s
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 82542622
o Age. J Alle gy Clin Immunol (2003) 112(5):973–80. doi: 10.1016/
j.jaci.2003.07.003
77. Max Ande sen MLC, Hougaa d P, Pö ksen S, Nielsen LB, F edheim S,
S ensson J, e al. Pa ial Remission Defini ion: Valida ion Based on he
Insulin Dose-Adjus ed HbA1c (IDAA1C) in 129 Danish Child en Wi h
New-Onse Type 1 Diabe es. Pedia Diabe es (2014) 15(7):469–76.
doi: 10.1111/pedi.12208
Conflic o In e es : Un ela ed o he wo k he ein p esen ed, MVP holds a pa en
ha ela es o immuno he apy o T1D and is co- ounde o Ahead The apeu ics
SL, and SRF is pa - ime employed a Ahead The apeu ics S.L. The o he au ho s
decla e ha he esea ch was conduc ed in he absence o any comme cial o
financial ela ionships ha could be cons ued as a po en ial conflic o in e es .
Publishe ’s No e: All claims exp essed in his a icle a e solely hose o he au ho s
and do no necessa ily ep esen hose o hei a filia ed o ganiza ions, o hose o
he publishe , he edi o s and he e iewe s. Any p oduc ha may be e alua ed in
his a icle, o claim ha may be made by i s manu ac u e , is no gua an eed o
endo sed by he publishe .
Copy igh © 2022 Gomez-Muñoz, Pe na-Ba ull, Ca oz-A mayones, Mu illo,
Rod iguez-Fe nandez, Valls, Vazquez, Pe ez, Co ipio, Cas año, Bel and Vi es-Pi.
This is an open-access a icle dis ibu ed unde he e ms o he C ea i e Commons
A ibu ion License (CC BY). The use, dis ibu ion o ep oduc ion in o he o ums is
pe mi ed, p o ided he o iginal au ho (s) and he copy igh owne (s) a e c edi ed and
ha he o iginal publica ion in his jou nal is ci ed, in acco dance wi h accep ed
academic p ac ice. No use, dis ibu ion o ep oduc ion is pe mi ed which does no
comply wi h hese e ms.
Gomez-Muñoz e al. Bioma ke s o Au oimmune Diabe es Remission
F on ie s in Immunology | www. on ie sin.o g Feb ua y 2022 | Volume 13 | A icle 82542623
