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Yang L, Ruan Y, Xu H. HIST3H2A promotes the progression of prostate cancer through inhibiting cell necroptosis. BMC Cancer 2024; 24:544. [PMID: 38684944 PMCID: PMC11059659 DOI: 10.1186/s12885-024-12308-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 04/24/2024] [Indexed: 05/02/2024] Open
Abstract
In recent years, there has been an increase in the incidence and mortality rates of prostate cancer (PCa). However, the specific molecular mechanisms underlying its occurrence and development remain unclear, necessitating the identification of new therapeutic targets. Through bioinformatics analysis, we discovered a previously unstudied differential gene called HIST3H2A in prostate cancer. Our study revealed that HIST3H2A is highly expressed in PCa tissues, as confirmed by analysis of both the GEO and UALCAN databases. Further analysis using the KEGG database demonstrated that HIST3H2A regulates the pathway of programmed necroptosis in cells. Additionally, we observed significant up-regulation of HIST3H2A in PCa tissues and cell lines. HIST3H2A was found to regulate cell proliferation, migration, invasion, and the epithelial-mesenchymal transition (EMT) process in tumors. Notably, HIST3H2A's role in regulating programmed necroptosis in prostate cancer cells differs from its role in apoptosis. In vitro and in vivo experiments collectively support the key role of HIST3H2A in promoting the development of prostate cancer, highlighting its potential as a therapeutic target for patients with PCa.
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Affiliation(s)
- Lihong Yang
- Key Laboratory of Animal Genetics, Breeding and Reproduction in the Plateau Mountainous Region, Ministry of Education, College of Life Sciences, Guizhou University, Guiyang, 550025, China
| | - Yong Ruan
- College of Animal Science, Guizhou University, Guiyang, 550025, China
| | - Houqiang Xu
- Key Laboratory of Animal Genetics, Breeding and Reproduction in the Plateau Mountainous Region, Ministry of Education, College of Life Sciences, Guizhou University, Guiyang, 550025, China.
- College of Animal Science, Guizhou University, Guiyang, 550025, China.
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Driggers CM, Kuo YY, Zhu P, ElSheikh A, Shyng SL. Structure of an open K ATP channel reveals tandem PIP 2 binding sites mediating the Kir6.2 and SUR1 regulatory interface. Nat Commun 2024; 15:2502. [PMID: 38509107 PMCID: PMC10954709 DOI: 10.1038/s41467-024-46751-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/08/2024] [Indexed: 03/22/2024] Open
Abstract
ATP-sensitive potassium (KATP) channels, composed of four pore-lining Kir6.2 subunits and four regulatory sulfonylurea receptor 1 (SUR1) subunits, control insulin secretion in pancreatic β-cells. KATP channel opening is stimulated by PIP2 and inhibited by ATP. Mutations that increase channel opening by PIP2 reduce ATP inhibition and cause neonatal diabetes. Although considerable evidence has implicated a role for PIP2 in KATP channel function, previously solved open-channel structures have lacked bound PIP2, and mechanisms by which PIP2 regulates KATP channels remain unresolved. Here, we report the cryoEM structure of a KATP channel harboring the neonatal diabetes mutation Kir6.2-Q52R, in the open conformation, bound to amphipathic molecules consistent with natural C18:0/C20:4 long-chain PI(4,5)P2 at two adjacent binding sites between SUR1 and Kir6.2. The canonical PIP2 binding site is conserved among PIP2-gated Kir channels. The non-canonical PIP2 binding site forms at the interface of Kir6.2 and SUR1. Functional studies demonstrate both binding sites determine channel activity. Kir6.2 pore opening is associated with a twist of the Kir6.2 cytoplasmic domain and a rotation of the N-terminal transmembrane domain of SUR1, which widens the inhibitory ATP binding pocket to disfavor ATP binding. The open conformation is particularly stabilized by the Kir6.2-Q52R residue through cation-π bonding with SUR1-W51. Together, these results uncover the cooperation between SUR1 and Kir6.2 in PIP2 binding and gating, explain the antagonistic regulation of KATP channels by PIP2 and ATP, and provide a putative mechanism by which Kir6.2-Q52R stabilizes an open channel to cause neonatal diabetes.
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Affiliation(s)
- Camden M Driggers
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health & Science University, Portland, OR, 97239, USA.
| | - Yi-Ying Kuo
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Phillip Zhu
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health & Science University, Portland, OR, 97239, USA
| | - Assmaa ElSheikh
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health & Science University, Portland, OR, 97239, USA
- Department of Medical Biochemistry, Tanta University, Tanta, Egypt
| | - Show-Ling Shyng
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health & Science University, Portland, OR, 97239, USA.
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Chang G, Ying L, Zhang Q, Feng B, Yao R, Ding Y, Li J, Huang X, Shen Y, Yu T, Wang J, Wang X. Genetic variants of ABCC8 and clinical manifestations in eight Chinese children with hyperinsulinemic hypoglycemia. BMC Endocr Disord 2024; 24:8. [PMID: 38212772 PMCID: PMC10785495 DOI: 10.1186/s12902-023-01527-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 12/06/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND ABCC8 variants can cause hyperinsulinemia by activating or deactivating gene expression. This study used targeted exon sequencing to investigate genetic variants of ABCC8 and the associated phenotypic features in Chinese patients with hyperinsulinemic hypoglycemia (HH). METHODS We enrolled eight Chinese children with HH and analyzed their clinical characteristics, laboratory results, and genetic variations. RESULTS The age at presentation among the patients ranged from neonates to 0.6 years old, and the age at diagnosis ranged from 1 month to 5 years, with an average of 1.3 ± 0.7 years. Among these patients, three presented with seizures, and five with hypoglycemia. One patient (Patient 7) also had microcephaly. All eight patients exhibited ABCC8 abnormalities, including six missense mutations (c. 2521 C > G, c. 3784G > A, c. 4478G > A, c. 4532T > C, c. 2669T > C, and c. 331G > A), two deletion-insertion mutations (c. 3126_3129delinsTC and c. 3124_3126delins13), and one splicing mutation (c. 1332 + 2T > C). Two of these mutations (c. 3126_3129delinsTC and c. 4532T > C) are novel. Six variations were paternal, two were maternal, and one was de novo. Three patients responded to diazoxide and one patient responded to octreotide treatment. All there patients had diazoxide withdrawal with age. Two patients (patients 3 and 7) were unresponsive to both diazoxide and octreotide and had mental retardation. CONCLUSIONS Gene analysis can aid in the classification, treatment, and prognosis of children with HH. In this study, the identification of seven known and two novel variants in the ABCC8 gene further enriched the variation spectrum of the gene.
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Affiliation(s)
- Guoying Chang
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China
| | - Lingwen Ying
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China
| | - Qianwen Zhang
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China
| | - Biyun Feng
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China
| | - Ruen Yao
- Department of Medical Genetics and Molecular Diagnostics laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 200127, Shanghai, China
| | - Yu Ding
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China
| | - Juan Li
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China
| | - Xiaodong Huang
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China
| | - Yongnian Shen
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China
| | - Tingting Yu
- Department of Medical Genetics and Molecular Diagnostics laboratory, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 200127, Shanghai, China
| | - Jian Wang
- International Peace Maternity and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, 200030, Shanghai, China.
| | - Xiumin Wang
- Department of Endocrinology and Metabolism, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, 200127, Shanghai, China.
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Driggers CM, Kuo YY, Zhu P, ElSheikh A, Shyng SL. Structure of an open K ATP channel reveals tandem PIP 2 binding sites mediating the Kir6.2 and SUR1 regulatory interface. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2023.08.01.551546. [PMID: 37577494 PMCID: PMC10418277 DOI: 10.1101/2023.08.01.551546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
ATP-sensitive potassium (K ATP ) channels, composed of four pore-lining Kir6.2 subunits and four regulatory sulfonylurea receptor 1 (SUR1) subunits, control insulin secretion in pancreatic β-cells. K ATP channel opening is stimulated by PIP 2 and inhibited by ATP. Mutations that increase channel opening by PIP 2 reduce ATP inhibition and cause neonatal diabetes. Although considerable evidence has indicated PIP 2 in K ATP channel function, previously solved open-channel structures have lacked bound PIP 2 , and mechanisms by which PIP 2 regulates K ATP channels remain unresolved. Here, we report the cryoEM structure of a K ATP channel harboring the neonatal diabetes mutation Kir6.2-Q52R, bound to natural C18:0/C20:4 long-chain PIP 2 in an open conformation. The structure reveals two adjacent PIP 2 molecules between SUR1 and Kir6.2. The first PIP 2 binding site is conserved among PIP 2 -gated Kir channels. The second site forms uniquely in K ATP at the interface of Kir6.2 and SUR1. Functional studies demonstrate both binding sites determine channel activity. Kir6.2 pore opening is associated with a twist of the Kir6.2 cytoplasmic domain and a rotation of the N-terminal transmembrane domain of SUR1, which widens the inhibitory ATP binding pocket to disfavor ATP binding. The open conformation is particularly stabilized by the Kir6.2-Q52R residue through cation-π bonding with SUR1-W51. Together, these results uncover the cooperation between SUR1 and Kir6.2 in PIP 2 binding and gating, explain the antagonistic regulation of K ATP channels by PIP 2 and ATP, and provide the mechanism by which Kir6.2-Q52R stabilizes an open channel to cause neonatal diabetes.
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Guzman H, Yazdani S, Harmon JL, Chapman KA, Vitola B, Pyle L, McKnight H, Sigal W, Lord K, De Leon DD, Merchant N, Ganetzky R. Case report: Two unexpected cases of DGUOK-related mitochondrial DNA depletion syndrome presenting with hyperinsulinemic hypoglycemia. Front Endocrinol (Lausanne) 2023; 14:1268135. [PMID: 38027095 PMCID: PMC10646319 DOI: 10.3389/fendo.2023.1268135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/02/2023] [Indexed: 12/01/2023] Open
Abstract
Timely diagnosis of persistent neonatal hypoglycemia is critical to prevent neurological sequelae, but diagnosis is complicated by the heterogenicity of the causes. We discuss two cases at separate institutions in which clinical management was fundamentally altered by the results of molecular genetic testing. In both patients, critical samples demonstrated hypoketotic hypoglycemia and a partial glycemic response to glucagon stimulation, thereby suggesting hyperinsulinism (HI). However, due to rapid genetic testing, both patients were found to have deoxyguanosine kinase (DGUOK)-related mitochondrial DNA depletion syndrome, an unexpected diagnosis. Patients with this disease typically present with either hepatocerebral disease in the neonatal period or isolated hepatic failure in infancy. The characteristic features involved in the hepatocerebral form of the disease include lactic acidosis, hypoglycemia, cholestasis, progressive liver failure, and increasing neurologic dysfunction. Those with isolated liver involvement experience hepatomegaly, cholestasis, and liver failure. Although liver transplantation is considered, research has demonstrated that for patients with DGUOK-related mitochondrial DNA depletion syndrome and neurologic symptoms, early demise occurs. Our report advocates for the prompt initiation of genetic testing in patients presenting with persistent neonatal hypoglycemia and for the incorporation of mitochondrial DNA depletion syndromes in the differential diagnosis of HI.
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Affiliation(s)
- Herodes Guzman
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Division of Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sahr Yazdani
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jennifer L. Harmon
- Rare Disease Institute, Children’s National Hospital, Washington, DC, United States
| | - Kimberly A. Chapman
- Rare Disease Institute, Children’s National Hospital, Washington, DC, United States
| | - Bernadette Vitola
- Division of Gastroenterology, Hepatology and Nutrition, Children’s National Hospital, Washington, DC, United States
- Transplant Institute, MedStar Georgetown University Hospital, Washington, DC, United States
| | - Louise Pyle
- Rare Disease Institute, Children’s National Hospital, Washington, DC, United States
| | - Heather McKnight
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Winnie Sigal
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Katherine Lord
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Diva D. De Leon
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Nadia Merchant
- Rare Disease Institute, Children’s National Hospital, Washington, DC, United States
- Division of Endocrinology and Diabetes, Children’s National Hospital, Washington, DC, United States
| | - Rebecca Ganetzky
- Division of Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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Clemente M, Cobo P, Antolín M, Campos A, Yeste D, Tomasini R, Caimari M, Masas M, García-Arumí E, Fernández-Cancio M, Baz-Redón N, Camats-Tarruella N. Genetics and Natural History of Non-pancreatectomized Patients With Congenital Hyperinsulinism Due to Variants in ABCC8. J Clin Endocrinol Metab 2023; 108:e1316-e1328. [PMID: 37216904 DOI: 10.1210/clinem/dgad280] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023]
Abstract
CONTEXT Patients with congenital hyperinsulinism due to ABCC8 variants generally present severe hypoglycemia and those who do not respond to medical treatment typically undergo pancreatectomy. Few data exist on the natural history of non-pancreatectomized patients. OBJECTIVE This work aims to describe the genetic characteristics and natural history in a cohort of non-pancreatectomized patients with congenital hyperinsulinism due to variants in the ABCC8 gene. METHODS Ambispective study of patients with congenital hyperinsulinism with pathogenic or likely pathogenic variants in ABCC8 treated in the last 48 years and who were not pancreatectomized. Continuous glucose monitoring (CGM) has been periodically performed in all patients since 2003. An oral glucose tolerance test was performed if hyperglycemia was detected in the CGM. RESULTS Eighteen non-pancreatectomized patients with ABCC8 variants were included. Seven (38.9%) patients were heterozygous, 8 (44.4%) compound heterozygous, 2 (11.1%) homozygous, and 1 patient carried 2 variants with incomplete familial segregation studies. Seventeen patients were followed up and 12 (70.6%) of them evolved to spontaneous resolution (median age 6.0 ± 4 years; range, 1-14). Five of these 12 patients (41.7%) subsequently progressed to diabetes with insufficient insulin secretion. Evolution to diabetes was more frequent in patients with biallelic variants in the ABCC8 gene. CONCLUSION The high remission rate observed in our cohort makes conservative medical treatment a reliable strategy for the management of patients with congenital hyperinsulinism due to ABCC8 variants. In addition, a periodic follow-up of glucose metabolism after remission is recommended, as a significant proportion of patients evolved to impaired glucose tolerance or diabetes (biphasic phenotype).
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Affiliation(s)
- María Clemente
- Paediatric Endocrinology Section, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Growth and Development Research Group, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Paediatrics, Obstetrics and Gynaecology and Preventive Medicine Department, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 08035 Barcelona, Spain
| | - Patricia Cobo
- Paediatric Endocrinology Section, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
| | - María Antolín
- Department of Clinical and Molecular Genetics and Rare Diseases, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Medicine Genetics Group, VHIR, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
| | - Ariadna Campos
- Paediatric Endocrinology Section, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Growth and Development Research Group, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Paediatrics, Obstetrics and Gynaecology and Preventive Medicine Department, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
| | - Diego Yeste
- Paediatric Endocrinology Section, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Growth and Development Research Group, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Paediatrics, Obstetrics and Gynaecology and Preventive Medicine Department, Universitat Autònoma de Barcelona, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 08035 Barcelona, Spain
| | - Rosangela Tomasini
- Paediatric Endocrinology Unit, Hospital Universitari Mútua Terrassa, 08021 Terrassa, Spain
| | - María Caimari
- Paediatric Endocrinology, Hospital Universitari Son Espases, 07120 Palma de Mallorca, Spain
| | - Miriam Masas
- Department of Clinical and Molecular Genetics and Rare Diseases, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Medicine Genetics Group, VHIR, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
| | - Elena García-Arumí
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 08035 Barcelona, Spain
- Department of Clinical and Molecular Genetics and Rare Diseases, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Medicine Genetics Group, VHIR, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Research Group on Neuromuscular and Mitochondrial Disorders, VHIR, Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
| | - Mónica Fernández-Cancio
- Growth and Development Research Group, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 08035 Barcelona, Spain
| | - Noelia Baz-Redón
- Growth and Development Research Group, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 08035 Barcelona, Spain
| | - Núria Camats-Tarruella
- Growth and Development Research Group, Vall d'Hebron Research Institute (VHIR), Hospital Universitari Vall d'Hebron, 08035 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Instituto de Salud Carlos III, 08035 Barcelona, Spain
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St-Louis JL, El Jellas K, Velasco K, Slipp BA, Hu J, Helgeland G, Steine SJ, De Jesus DF, Kulkarni RN, Molven A. Deficiency of the metabolic enzyme SCHAD in pancreatic β-cells promotes amino acid-sensitive hypoglycemia. J Biol Chem 2023; 299:104986. [PMID: 37392854 PMCID: PMC10407745 DOI: 10.1016/j.jbc.2023.104986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/02/2023] [Accepted: 06/20/2023] [Indexed: 07/03/2023] Open
Abstract
Congenital hyperinsulinism of infancy (CHI) can be caused by a deficiency of the ubiquitously expressed enzyme short-chain 3-hydroxyacyl-CoA dehydrogenase (SCHAD). To test the hypothesis that SCHAD-CHI arises from a specific defect in pancreatic β-cells, we created genetically engineered β-cell-specific (β-SKO) or hepatocyte-specific (L-SKO) SCHAD knockout mice. While L-SKO mice were normoglycemic, plasma glucose in β-SKO animals was significantly reduced in the random-fed state, after overnight fasting, and following refeeding. The hypoglycemic phenotype was exacerbated when the mice were fed a diet enriched in leucine, glutamine, and alanine. Intraperitoneal injection of these three amino acids led to a rapid elevation in insulin levels in β-SKO mice compared to controls. Consistently, treating isolated β-SKO islets with the amino acid mixture potently enhanced insulin secretion compared to controls in a low-glucose environment. RNA sequencing of β-SKO islets revealed reduced transcription of β-cell identity genes and upregulation of genes involved in oxidative phosphorylation, protein metabolism, and Ca2+ handling. The β-SKO mouse offers a useful model to interrogate the intra-islet heterogeneity of amino acid sensing given the very variable expression levels of SCHAD within different hormonal cells, with high levels in β- and δ-cells and virtually absent α-cell expression. We conclude that the lack of SCHAD protein in β-cells results in a hypoglycemic phenotype characterized by increased sensitivity to amino acid-stimulated insulin secretion and loss of β-cell identity.
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Affiliation(s)
- Johanna L St-Louis
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Medical School, Boston, USA; Department of Clinical Medicine, Gade Laboratory for Pathology, University of Bergen, Bergen, Norway
| | - Khadija El Jellas
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Medical School, Boston, USA; Department of Clinical Medicine, Gade Laboratory for Pathology, University of Bergen, Bergen, Norway
| | - Kelly Velasco
- Department of Clinical Medicine, Gade Laboratory for Pathology, University of Bergen, Bergen, Norway
| | - Brittany A Slipp
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Medical School, Boston, USA
| | - Jiang Hu
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Medical School, Boston, USA
| | - Geir Helgeland
- Department of Clinical Medicine, Gade Laboratory for Pathology, University of Bergen, Bergen, Norway
| | - Solrun J Steine
- Department of Clinical Medicine, Gade Laboratory for Pathology, University of Bergen, Bergen, Norway
| | - Dario F De Jesus
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Medical School, Boston, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA; Harvard Stem Cell Institute, Boston, USA
| | - Rohit N Kulkarni
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Medical School, Boston, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, USA; Harvard Stem Cell Institute, Boston, USA
| | - Anders Molven
- Department of Clinical Medicine, Gade Laboratory for Pathology, University of Bergen, Bergen, Norway; Department of Pathology, Haukeland University Hospital, Bergen, Norway; Section for Cancer Genomics, Haukeland University Hospital, Bergen, Norway.
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8
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Dieterle MP, Husari A, Prozmann SN, Wiethoff H, Stenzinger A, Röhrich M, Pfeiffer U, Kießling WR, Engel H, Sourij H, Steinberg T, Tomakidi P, Kopf S, Szendroedi J. Diffuse, Adult-Onset Nesidioblastosis/Non-Insulinoma Pancreatogenous Hypoglycemia Syndrome (NIPHS): Review of the Literature of a Rare Cause of Hyperinsulinemic Hypoglycemia. Biomedicines 2023; 11:1732. [PMID: 37371827 DOI: 10.3390/biomedicines11061732] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/13/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
Differential diagnosis of hypoglycemia in the non-diabetic adult patient is complex and comprises various diseases, including endogenous hyperinsulinism caused by functional β-cell disorders. The latter is also designated as nesidioblastosis or non-insulinoma pancreatogenous hypoglycemia syndrome (NIPHS). Clinically, this rare disease presents with unspecific adrenergic and neuroglycopenic symptoms and is, therefore, often overlooked. A combination of careful clinical assessment, oral glucose tolerance testing, 72 h fasting, sectional and functional imaging, and invasive insulin measurements can lead to the correct diagnosis. Due to a lack of a pathophysiological understanding of the condition, conservative treatment options are limited and mostly ineffective. Therefore, nearly all patients currently undergo surgical resection of parts or the entire pancreas. Consequently, apart from faster diagnosis, more elaborate and less invasive treatment options are needed to relieve the patients from the dangerous and devastating symptoms. Based on a case of a 23-year-old man presenting with this disease in our department, we performed an extensive review of the medical literature dealing with this condition and herein presented a comprehensive discussion of this interesting disease, including all aspects from epidemiology to therapy.
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Affiliation(s)
- Martin Philipp Dieterle
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Ayman Husari
- Department of Orthodontics, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Sophie Nicole Prozmann
- Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Hendrik Wiethoff
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Albrecht Stenzinger
- Institute of Pathology, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Manuel Röhrich
- Department of Nuclear Medicine, University Hospital Heidelberg, 69120 Heidelberg, Germany
| | - Uwe Pfeiffer
- Pfalzklinikum for Psychiatry and Neurology AdÖR, Weinstr. 100, 76889 Klingenmünster, Germany
| | | | - Helena Engel
- Cancer Immune Regulation Group, German Cancer Research Center, Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Harald Sourij
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, 8010 Graz, Austria
- Interdisciplinary Metabolic Medicine Trials Unit, Medical University of Graz, 8010 Graz, Austria
| | - Thorsten Steinberg
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Pascal Tomakidi
- Division of Oral Biotechnology, Center for Dental Medicine, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetterstr. 55, 79106 Freiburg, Germany
| | - Stefan Kopf
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine I and Clinical Chemistry, University of Heidelberg, 69120 Heidelberg, Germany
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9
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Martin GM, Patton BL, Shyng SL. K ATP channels in focus: Progress toward a structural understanding of ligand regulation. Curr Opin Struct Biol 2023; 79:102541. [PMID: 36807078 PMCID: PMC10023423 DOI: 10.1016/j.sbi.2023.102541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 12/11/2022] [Accepted: 01/14/2023] [Indexed: 02/21/2023]
Abstract
KATP channels are hetero-octameric complexes of four inward rectifying potassium channels, Kir6.1 or Kir6.2, and four sulfonylurea receptors, SUR1, SUR2A, or SUR2B from the ABC transporter family. This unique combination enables KATP channels to couple intracellular ATP/ADP ratios, through gating, with membrane excitability, thus regulating a broad range of cellular activities. The prominence of KATP channels in human physiology, disease, and pharmacology has long attracted research interest. Since 2017, a steady flow of high-resolution KATP cryoEM structures has revealed complex and dynamic interactions between channel subunits and their ligands. Here, we highlight insights from recent structures that begin to provide mechanistic explanations for decades of experimental data and discuss the remaining knowledge gaps in our understanding of KATP channel regulation.
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Affiliation(s)
- Gregory M Martin
- Department of Integrative Structural and Computational Biology, The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Bruce L Patton
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health and Science University, Portland, OR, 97239, USA
| | - Show-Ling Shyng
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health and Science University, Portland, OR, 97239, USA.
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10
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ElSheikh A, Shyng SL. K ATP channel mutations in congenital hyperinsulinism: Progress and challenges towards mechanism-based therapies. Front Endocrinol (Lausanne) 2023; 14:1161117. [PMID: 37056678 PMCID: PMC10086357 DOI: 10.3389/fendo.2023.1161117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycemia in infancy/childhood and is a serious condition associated with severe recurrent attacks of hypoglycemia due to dysregulated insulin secretion. Timely diagnosis and effective treatment are crucial to prevent severe hypoglycemia that may lead to life-long neurological complications. In pancreatic β-cells, adenosine triphosphate (ATP)-sensitive K+ (KATP) channels are a central regulator of insulin secretion vital for glucose homeostasis. Genetic defects that lead to loss of expression or function of KATP channels are the most common cause of HI (KATP-HI). Much progress has been made in our understanding of the molecular genetics and pathophysiology of KATP-HI in the past decades; however, treatment remains challenging, in particular for patients with diffuse disease who do not respond to the KATP channel activator diazoxide. In this review, we discuss current approaches and limitations on the diagnosis and treatment of KATP-HI, and offer perspectives on alternative therapeutic strategies.
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Affiliation(s)
- Assmaa ElSheikh
- Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, Portland, OR, United States
- Department of Medical Biochemistry, Tanta University, Tanta, Egypt
| | - Show-Ling Shyng
- Department of Chemical Physiology and Biochemistry, Oregon Health & Science University, Portland, OR, United States
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11
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Spagnoletti G, Larghi Laureiro Z, Maria Fratti A, Maiorana A, Garganese MC, Pizzoferro M, Dionisi-Vici C, Spada M. Case report: Pylorus-preserving pancreatoduodenectomy for focal congenital hyperinsulinism in a 5-month-old baby. Front Surg 2023; 9:1085238. [PMID: 36793512 PMCID: PMC9923011 DOI: 10.3389/fsurg.2022.1085238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/19/2022] [Indexed: 01/31/2023] Open
Abstract
Background In focal congenital hyperinsulinism (CHI), surgery is the gold standard of treatment, even for lesions localized in the head of the pancreas. We report the video of the pylorus-preserving pancreatoduodenectomy performed in a five-month-old child with focal CHI. Operative technique Baby was placed in the supine position with both arms outstretched to the up. After transverse supraumbilical incision and mobilization of ascending and transverse colon, exploration and multiple biopsies of the tail and the body of the pancreas ruled out multifocality. Pylorus-preserving pancreatoduodenectomy was performed according to the following steps: extended Kocher maneuver, followed by retrograde cholecystectomy and common bile duct isolation; division of the gastroduodenal artery and of the gastrocolic ligament; division of the duodenum, Treitz ligament and jejunum; transection of the pancreatic body. The reconstructive time was with: pancreato-jejunostomy; hepaticojejunostomy; pilorus-preserving antecolic duodeno-jejunostomy. The anastomoses were accomplished with synthetic absorbable monofilament sutures; two drains were placed close to the biliary and pancreatic anastomoses and to the intestinal anastomosis, respectively. Total operative time was 6 h, with no blood loss and/or intra-operative complications, immediate normalization of blood glucose levels and discharge from surgical ward 19 days after surgery. Conclusions Surgical treatment of medical unresponsive focal forms of CHI is feasible in very small children: it is mandatory to refer the baby to a high-volume centre for a multidisciplinary management involving hepato-bilio-pancreatic surgeons and experts in metabolic disease.
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Affiliation(s)
- Gionata Spagnoletti
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Zoe Larghi Laureiro
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Alberto Maria Fratti
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Arianna Maiorana
- Division of Metabolic Diseases, Department of Pediatric Specialties, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Maria Carmen Garganese
- Nuclear Medicine, Imaging Department Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Milena Pizzoferro
- Nuclear Medicine, Imaging Department Ospedale Pediatrico Bambino Gesù, IRCCS, Roma, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases, Department of Pediatric Specialties, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Marco Spada
- Division of Hepatobiliopancreatic Surgery, Liver and Kidney Transplantation, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy,Correspondence: Marco Spada
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12
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Gundogdu S, Ciftci M, Atay E, Ayaz A, Ceran O, Atay Z. Clinical and laboratory evaluation of children with congenital hyperinsulinism: a single center experience. J Pediatr Endocrinol Metab 2023; 36:53-57. [PMID: 36409572 DOI: 10.1515/jpem-2022-0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 10/26/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To evaluate and present the data regarding clinical, laboratory, radiological and the results of molecular genetic analysis of patients with hyperinsulinemic hypoglycemia in our clinics. METHODS A total of 9 patients with CHI followed at Istanbul Medipol University. Data related to gender, age at presentation, birth weight, gestational age, consanguinity, glucose and insulin levels at diagnosis, treatment modalities, response to treatment, the results of genetic analysis and radiological evaluation were gathered from the files. RESULTS The oldest age at presentation was 6 months. KATP channel mutation was detected in 55% (n: 5). Diazoxide unresponsiveness was seen in 55% (n: 5). Octreotide was effective in 3 of them. 18F-DOPA PET performed in 4 diazoxide unresponsive patients revealed focal lesion in 3 of them. Spontaneous remission rate was 66% (n:6). All the patients with normal genetic result achieved spontaneous remission. Spontaneous remission was even noted in diazoxide unresponsive patients and in patients with focal lesion on 18F-DOPA PET. CONCLUSIONS Clinical presentation of patients with congenital hypereinsulinism is heterogeneous. Spontaneous remission rate is quite high even in patients with severe clinical presentation. It is important to develop methods that can predict which patients will have spontaneous remission. Reporting the clinical and laboratory data of each patient is important and will help to guide the management of patients with hyperinsulinemic hypoglycemia.
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Affiliation(s)
- Semra Gundogdu
- Department of Neonatalogy, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Mustafa Ciftci
- Department of Pediatrics, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Enver Atay
- Department of Pediatrics, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Akif Ayaz
- Genetic Diseases Assessment Center, Istanbul Medipol University, Istanbul, Turkey
| | - Omer Ceran
- Department of Pediatrics, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
| | - Zeynep Atay
- Department of Pediatric Endocrinology, Istanbul Medipol University, School of Medicine, Istanbul, Turkey
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13
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Boskabadi SJ, Ramezaninejad S, Sohrab M, Farhadi R. Diazoxide-Induced Hypertrichosis in a Neonate With Transient Hyperinsulinism. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2023; 16:11795476231151330. [PMID: 36726424 PMCID: PMC9885027 DOI: 10.1177/11795476231151330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 12/28/2022] [Indexed: 01/28/2023]
Abstract
Diazoxide is one of the FDA-approved pharmacologic treatments for hyperinsulinemic hypoglycemia, however, its adverse effects in infants are not well described. We reported a 37-week-old boy with the diagnosis of hypoglycemia. We started a dextrose infusion, but we used oral diazoxide, due to hypoglycemia episodes despite the increase in dextrose intake. The newborn had a normoglycemic condition after gradually increasing the diazoxide dose to 15 mg/kg/day. He was fully breastfed and discharged at 14 days of age with ongoing diazoxide. In weekly serial clinical follow-ups, the parents noticed an increase in the growth of forehead and facial hair that was diagnosed as diazoxide-induced hypertrichosis. Diazoxide was gradually tapered, and hypertrichosis continued until 1 month after dioxide discontinuation. Diazoxide use in NICU settings has increased over time. Diazoxide has many side effects, one of which is hypertrichosis. Many diazoxide side effects have been reported in adults or children and few studies have reported the prevalence of these adverse effects of diazoxide in neonates and infants.
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Affiliation(s)
- Seyyed Javad Boskabadi
- Department of Clinical Pharmacy,
Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Sima Ramezaninejad
- Department of Clinical Pharmacy,
Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Masoumeh Sohrab
- Department of Clinical Pharmacy,
Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Roya Farhadi
- Department of Neonatology, Pediatrics
Infectious Diseases Research Center, Mazandaran University of Medical Sciences,
Sari, Iran,Roya Farhadi, Department of Neonatology,
Pediatrics Infectious Diseases Research Center, Mazandaran University of Medical
Sciences, Sari, Iran; Division of neonatology, Department of Pediatrics, Boo Ali
Sina Hospital, Pasdaran Boulevard, P.O.Box 48158-38477, Sari, Iran. Emails:
;
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14
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Zenker M, Mohnike K, Palm K. Syndromic forms of congenital hyperinsulinism. Front Endocrinol (Lausanne) 2023; 14:1013874. [PMID: 37065762 PMCID: PMC10098214 DOI: 10.3389/fendo.2023.1013874] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 03/07/2023] [Indexed: 04/18/2023] Open
Abstract
Congenital hyperinsulinism (CHI), also called hyperinsulinemic hypoglycemia (HH), is a very heterogeneous condition and represents the most common cause of severe and persistent hypoglycemia in infancy and childhood. The majority of cases in which a genetic cause can be identified have monogenic defects affecting pancreatic β-cells and their glucose-sensing system that regulates insulin secretion. However, CHI/HH has also been observed in a variety of syndromic disorders. The major categories of syndromes that have been found to be associated with CHI include overgrowth syndromes (e.g. Beckwith-Wiedemann and Sotos syndromes), chromosomal and monogenic developmental syndromes with postnatal growth failure (e.g. Turner, Kabuki, and Costello syndromes), congenital disorders of glycosylation, and syndromic channelopathies (e.g. Timothy syndrome). This article reviews syndromic conditions that have been asserted by the literature to be associated with CHI. We assess the evidence of the association, as well as the prevalence of CHI, its possible pathophysiology and its natural course in the respective conditions. In many of the CHI-associated syndromic conditions, the mechanism of dysregulation of glucose-sensing and insulin secretion is not completely understood and not directly related to known CHI genes. Moreover, in most of those syndromes the association seems to be inconsistent and the metabolic disturbance is transient. However, since neonatal hypoglycemia is an early sign of possible compromise in the newborn, which requires immediate diagnostic efforts and intervention, this symptom may be the first to bring a patient to medical attention. As a consequence, HH in a newborn or infant with associated congenital anomalies or additional medical issues remains a differential diagnostic challenge and may require a broad genetic workup.
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Affiliation(s)
- Martin Zenker
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- *Correspondence: Martin Zenker,
| | - Klaus Mohnike
- Department of Pediatrics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katja Palm
- Department of Pediatrics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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15
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Driggers CM, Shyng SL. Mechanistic insights on KATP channel regulation from cryo-EM structures. J Gen Physiol 2022; 155:213723. [PMID: 36441147 PMCID: PMC9700523 DOI: 10.1085/jgp.202113046] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/19/2022] [Accepted: 11/08/2022] [Indexed: 11/29/2022] Open
Abstract
Gated by intracellular ATP and ADP, ATP-sensitive potassium (KATP) channels couple cell energetics with membrane excitability in many cell types, enabling them to control a wide range of physiological processes based on metabolic demands. The KATP channel is a complex of four potassium channel subunits from the Kir channel family, Kir6.1 or Kir6.2, and four sulfonylurea receptor subunits, SUR1, SUR2A, or SUR2B, from the ATP-binding cassette (ABC) transporter family. Dysfunction of KATP channels underlies several human diseases. The importance of these channels in human health and disease has made them attractive drug targets. How the channel subunits interact with one another and how the ligands interact with the channel to regulate channel activity have been long-standing questions in the field. In the past 5 yr, a steady stream of high-resolution KATP channel structures has been published using single-particle cryo-electron microscopy (cryo-EM). Here, we review the advances these structures bring to our understanding of channel regulation by physiological and pharmacological ligands.
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Affiliation(s)
- Camden M. Driggers
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health and Science University, Portland, OR
| | - Show-Ling Shyng
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health and Science University, Portland, OR,Correspondence to Show-Ling Shyng:
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16
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Perge K, Nicolino M. Variable phenotypes of individual and family monogenic cases with hyperinsulinism and diabetes: a systematic review. Rev Endocr Metab Disord 2022; 23:1063-1078. [PMID: 35996042 DOI: 10.1007/s11154-022-09749-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
Maturity-Onset Diabetes of the Youth (MODY) diabetes remains commonly misdiagnosed. A monogenic form should be suspected in individuals presenting hyperinsulinemic hypoglycemia (HH) associated with, either later development of MODY (hypoglycemia-remission-diabetes sequence), or with first/second-degree family history of diabetes. Herein, we aimed to describe this individual or family monogenic association between HH and diabetes, and identify potential genotype-phenotype correlations. We conducted a systematic review of 26 studies, including a total of 67 patients with this association resulting from variants in GCK (n = 5 cases), ABCC8 (n = 29), HNF1A (n = 5), or HNF4A (n = 28). A family history of hypoglycemia and/or diabetes was present in 91% of cases (61/67). Median age at first hypoglycemia was 24 h after birth. Diazoxide was initiated in 46 children (46/67-69%); responsiveness was found in 91% (42/46). Median HH duration was three years (1 day-25 years). Twenty-three patients (23/67-34%) later developed diabetes (median age: 13 years; range: 8-48); more frequently in those untreated with diazoxide. This association was most commonly inherited in an autosomal dominant manner (43/48-90%). Some genes were associated with less severe initial hypoglycemia (HNF1A), shorter duration of HH (HNF4A), and more maternal (ABCC8) or paternal (HNF4A) transmission. This study illustrates that the same genotype can give a biphasic phenotype in the same person or a reverse phenotype in the same family. Wider awareness of this association is necessary in pediatrics to establish annual monitoring of patients who have presented HH, and during maternity to screen diabetes and optimize genetic counseling and management of pregnancy, childbirth, and the newborn.PROSPERO registration: CRD42020178265.
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Affiliation(s)
- Kevin Perge
- Service d'Endocrinologie Pédiatrique Et Pédiatrie Générale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677, Bron, France
- Université Claude Bernard, Lyon 1, 8 Avenue Rockefeller, 69008, Lyon, France
| | - Marc Nicolino
- Service d'Endocrinologie Pédiatrique Et Pédiatrie Générale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677, Bron, France.
- Université Claude Bernard, Lyon 1, 8 Avenue Rockefeller, 69008, Lyon, France.
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17
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Kornya M, Abrams-Ogg A, Comeau D, Caswell J. Juvenile hyperinsulinism in a Maine Coon kitten. JFMS Open Rep 2022; 8:20551169221136473. [DOI: 10.1177/20551169221136473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Case summary A 5.5 month-old intact male Maine Coon cat was presented to a referral hospital for a history of muscle fasciculations, lethargy and seizures associated with refractory hypoglycemia. Diagnostic testing for hypothyroidism, hyposomatotropism or hypoadrenocorticism, inborn errors of metabolism (ie, storage diseases and urea cycle disorders), infection or iatrogenic hypoglycemia were negative. An inappropriately high serum insulin level was noted in the face of marked hypoglycemia. The insulin:glucose ratio was 0.44 (<0.3) and the amended insulin:glucose ratio was 1268 (<30). Thoracic radiography and abdominal ultrasonography did not identify a cause for this elevated insulin level. Stabilization with a low, but adequate, blood glucose occurred with corticosteroid therapy, with further significant improvement with the addition of diazoxide. Peripheral neuropathy developed several months later, and concerns for quality of life led to humane euthanasia approximately 1 year after the initial diagnosis. Insulin levels remained high at the time of euthanasia. Necropsy found no gross lesions, though microscopic degeneration of the sciatic nerve and subjectively mildly increased size and number of pancreatic islets was noted. These findings were consistent with a diagnosis of congenital hyperinsulinism. Relevance and novel information This is the first reported case of congenital hyperinsulinism in a cat and may parallel the diffuse form of hypoglycemic hyperinsulinism reported in humans and a single dog. It should be considered a differential diagnosis in kittens presenting for refractory hypoglycemia.
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Affiliation(s)
- Matthew Kornya
- Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | | | - Dominique Comeau
- Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
| | - Jeff Caswell
- Ontario Veterinary College, University of Guelph, Guelph, ON, Canada
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18
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Wang Z, Bian W, Yan Y, Zhang DM. Functional Regulation of KATP Channels and Mutant Insight Into Clinical Therapeutic Strategies in Cardiovascular Diseases. Front Pharmacol 2022; 13:868401. [PMID: 35837280 PMCID: PMC9274113 DOI: 10.3389/fphar.2022.868401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
ATP-sensitive potassium channels (KATP channels) play pivotal roles in excitable cells and link cellular metabolism with membrane excitability. The action potential converts electricity into dynamics by ion channel-mediated ion exchange to generate systole, involved in every heartbeat. Activation of the KATP channel repolarizes the membrane potential and decreases early afterdepolarization (EAD)-mediated arrhythmias. KATP channels in cardiomyocytes have less function under physiological conditions but they open during severe and prolonged anoxia due to a reduced ATP/ADP ratio, lessening cellular excitability and thus preventing action potential generation and cell contraction. Small active molecules activate and enhance the opening of the KATP channel, which induces the repolarization of the membrane and decreases the occurrence of malignant arrhythmia. Accumulated evidence indicates that mutation of KATP channels deteriorates the regulatory roles in mutation-related diseases. However, patients with mutations in KATP channels still have no efficient treatment. Hence, in this study, we describe the role of KATP channels and subunits in angiocardiopathy, summarize the mutations of the KATP channels and the functional regulation of small active molecules in KATP channels, elucidate the potential mechanisms of mutant KATP channels and provide insight into clinical therapeutic strategies.
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Affiliation(s)
- Zhicheng Wang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Weikang Bian
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yufeng Yan
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Dai-Min Zhang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Cardiology, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
- *Correspondence: Dai-Min Zhang,
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19
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Rossi A, Rutten MGS, van Dijk TH, Bakker BM, Reijngoud DJ, Oosterveer MH, Derks TGJ. Dynamic Methods for Childhood Hypoglycemia Phenotyping: A Narrative Review. Front Endocrinol (Lausanne) 2022; 13:858832. [PMID: 35789807 PMCID: PMC9249565 DOI: 10.3389/fendo.2022.858832] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 04/27/2022] [Indexed: 11/25/2022] Open
Abstract
Hypoglycemia results from an imbalance between glucose entering the blood compartment and glucose demand, caused by a defect in the mechanisms regulating postprandial glucose homeostasis. Hypoglycemia represents one of the most common metabolic emergencies in childhood, potentially leading to serious neurologic sequelae, including death. Therefore, appropriate investigation of its specific etiology is paramount to provide adequate diagnosis, specific therapy and prevent its recurrence. In the absence of critical samples for biochemical studies, etiological assessment of children with hypoglycemia may include dynamic methods, such as in vivo functional tests, and continuous glucose monitoring. By providing detailed information on actual glucose fluxes in vivo, proof-of-concept studies have illustrated the potential (clinical) application of dynamic stable isotope techniques to define biochemical and clinical phenotypes of inherited metabolic diseases associated with hypoglycemia. According to the textbooks, individuals with glycogen storage disease type I (GSD I) display the most severe hypoglycemia/fasting intolerance. In this review, three dynamic methods are discussed which may be considered during both diagnostic work-up and monitoring of children with hypoglycemia: 1) functional in vivo tests; 2) in vivo metabolic profiling by continuous glucose monitoring (CGM); 3) stable isotope techniques. Future applications and benefits of dynamic methods in children with hypoglycemia are also discussed.
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Affiliation(s)
- Alessandro Rossi
- Section of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Department of Translational Medicine, Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Martijn G S Rutten
- Laboratory of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Theo H van Dijk
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Barbara M Bakker
- Laboratory of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Dirk-Jan Reijngoud
- Laboratory of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Maaike H Oosterveer
- Laboratory of Pediatrics, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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20
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Reyes Diaz JV, Jin Y, Garber K, Cossen KM, Li Y, Jin P, Li H, Ham JYN. A homozygous exonic variant leading to exon skipping in ABCC8 as the cause of severe congenital hyperinsulinism. Am J Med Genet A 2022; 188:2429-2433. [PMID: 35621279 DOI: 10.1002/ajmg.a.62843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 02/19/2022] [Accepted: 04/15/2022] [Indexed: 12/13/2022]
Abstract
Congenital hyperinsulinism (CHI) is genetically heterogeneous, caused by pathogenic variants in multiple known genes regulating insulin secretion from the pancreatic β-cells. The ABCC8 gene encodes the sulfonylurea receptor 1 (SUR1), a key player in insulin secretion, and pathogenic variants in ABCC8 are the most common cause of CHI. With increased application of genetic testing in clinical practice, variants of unknown clinical significance (VUS) are commonly reported. Additional functional investigation for variant pathogenicity is fundamental in establishing definitive molecular diagnosis and in guiding clinical management. However, due to the lack of ubiquitous tissue expression of these genes, obtaining functional studies on affected tissue has been challenging. We present a case of severe congenital hyperinsulinism which required a near-total pancreatectomy. CHI gene sequencing identified a homozygous silent variant in ABCC8 located on the last nucleotide of exon 38, c.4608G>A (p.Ala1536Ala). The total RNA was isolated from pancreas resected at the time of pancreatectomy. RNA sequencing and expression analysis demonstrated exon 38 skipping and decreased RNA expression, which supports the pathogenicity of this variant. This case highlights the feasibility of functional studies of VUS on resected pancreatic tissue. The result expands the mutation spectrum in ABCC8 and allows precise genetic counseling to affected families.
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Affiliation(s)
- Jacqueline V Reyes Diaz
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Division of Endocrinology, Department of Pediatrics, Driscoll Children's Hospital, Corpus Christi, Texas, USA
| | - Yulin Jin
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kathryn Garber
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kristina M Cossen
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Yujing Li
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Peng Jin
- Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hong Li
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Department of Human Genetics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jee-Young Nina Ham
- Division of Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Atlanta, Georgia, USA.,Division of Endocrinology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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21
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Seetharaman SS, Topor LS. 50 Years Ago in TheJournalofPediatrics: Differentiating Focal Versus Diffuse Hyperinsulinism. J Pediatr 2022; 244:85. [PMID: 35534165 DOI: 10.1016/j.jpeds.2022.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | - Lisa Swartz Topor
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
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22
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Vossschulte H, Mohnike K, Mohnike K, Warncke K, Akcay A, Zenker M, Wieland I, Schanze I, Hoefele J, Förster C, Barthlen W, Stahlberg K, Empting S. Correlation of PET-MRI, pathology, LOH and surgical success in a case of CHI with atypical large pancreatic focus. J Endocr Soc 2022; 6:bvac056. [PMID: 35475025 PMCID: PMC9032632 DOI: 10.1210/jendso/bvac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Indexed: 11/19/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a rare cause of severe hypoglycemia in newborns. In focal CHI, usually one activity peak in fluorine-18-L-dihydroxyphenylalanine (18F-DOPA) positron emission tomography–magnetic resonance imaging (PET-MRI) indicates one focal lesion and its resection results in cure of the child. We present the case of a 5-month-old girl with CHI. Mutational screening of genes involved in CHI revealed a heterozygous pathogenic variant in the ABCC8 gene, which was not detectable in the parents. 18F-DOPA PET-MRI revealed 2 distinct activity peaks nearby in the pancreatic body and neck. Surgical resection of the tissue areas representing both activity peaks resulted in long-lasting normoglycemia that was proven by a fasting test. Molecular analysis of tissue samples from various sites provided evidence that a single second genetic hit in a pancreatic precursor cell was responsible for the atypical extended pancreatic lesion. There was a close correlation in the resected areas of PET-MRI activity with focal histopathology and frequency of the mutant allele (loss of heterozygosity) in the tissue. Focal lesions can be very heterogenous. The resection of the most affected areas as indicated by imaging, histopathology, and genetics could result in complete cure.
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Affiliation(s)
- Hendrik Vossschulte
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Germany
| | | | - Klaus Mohnike
- University Children’s Hospital, Otto-von-Guericke University Magdeburg, Germany
| | - Katharina Warncke
- Department of Pediatrics, Kinderklinik München Schwabing, Technical University of Munich, School of Medicine, Munich, Germany
| | - Ayse Akcay
- Department of Neonatology, Munich-Schwabing Municipal Hospitals, Munich, Germany
| | - Martin Zenker
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Germany
| | - Ilse Wieland
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Germany
| | - Ina Schanze
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Germany
| | - Julia Hoefele
- Institute of Human Genetics, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Christine Förster
- Institute of Pathology, Hospital Nordstadt, affiliated with the University Hospital of the University of Bielefeld, Campus Bielefeld Bethel, Hanover, Germany
| | - Winfried Barthlen
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Germany
| | - Kim Stahlberg
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Germany
| | - Susann Empting
- University Children’s Hospital, Otto-von-Guericke University Magdeburg, Germany
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23
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Congenital hyperinsulinism: localization of a focal lesion with 18F-FDOPA positron emission tomography. Pediatr Radiol 2022; 52:693-701. [PMID: 34668049 DOI: 10.1007/s00247-021-05206-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/29/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
Hyperinsulinemic hypoglycemia of infancy, also known as congenital hyperinsulinism, is a group of disorders characterized by dysregulated insulin release. Neonates with severe, persistent hyperinsulinemic hypoglycemia who are unresponsive to medical therapy require pancreatectomy to prevent brain damage from hypoglycemia. To date, multiple genetic mutations and syndromes and several unique histopathological entities have been identified in children with hyperinsulinism. Histopathology is characterized as diffuse, focal or atypical. Surgical resection of a focal lesion results in a cure in up to 97% of these children. Imaging with 6-fluoro-(18F)-L-3,4-dihydroxyphenylalanine (18F-FDOPA) positron emission tomography (PET) is the test of choice for identifying and localizing a focal lesion and has proved to be an invaluable guide for surgical resection. Genetic evaluation is essential for determining who will benefit from PET imaging. This article provides an approach to determine who should be imaged, how to set up a protocol and how to interpret the imaging findings. The diagnosis and management of this disorder require a multidisciplinary approach to prevent brain damage from hypoglycemia.
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Mazloom K, Sanchez-Lara PA, Langston S, Grand K, Schweiger B. Congenital hyperinsulinism in a newborn presenting with poor feeding. SAGE Open Med Case Rep 2022; 10:2050313X221083174. [PMID: 35371490 PMCID: PMC8966065 DOI: 10.1177/2050313x221083174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 02/06/2022] [Indexed: 11/16/2022] Open
Abstract
Hyperinsulinemic hypoglycemia is a condition linked to several genetic, metabolic, and growth disorders in which there is dysregulated insulin secretion. In infants, an inappropriately persistent hypoglycemic and hypoketotic state can cause severe brain injury leading to epilepsy, cerebral palsy, and neurodevelopmental disabilities due to the lack of glucose and ketone substrate to serve as fuel for the developing brain. The most common cause of persistent hypoglycemia in neonates and children has been found to be congenital hyperinsulinism. Here, we report a child with a unique presentation, found to have a novel genetic variant as the underlying cause of hyperinsulinism. This case study highlights the importance of maintaining a broad differential and considering a diagnosis of congenital hyperinsulinism in a baby with poor feeding in the newborn period. Recognizing and treating congenital hyperinsulinism is essential to prevent potential neurological sequelae from recurrent, severe hypoglycemia.
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Affiliation(s)
- Kiran Mazloom
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, USA
| | - Pedro A Sanchez-Lara
- Division of Medical Genetics, Department of Pediatrics, Cedars-Sinai Medical Center, Beverly Hills, CA, USA
| | - Seth Langston
- Division of Neonatology, Department of Pediatrics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Katheryn Grand
- Division of Medical Genetics, Department of Pediatrics, Cedars-Sinai Medical Center, Beverly Hills, CA, USA
| | - Bahareh Schweiger
- Department of Pediatric Endocrinology, Cedars-Sinai Medical Center, Beverly Hills, CA, USA
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25
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Hyperinsulinism. ENDOCRINES 2022. [DOI: 10.3390/endocrines3010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Congenital or monogenic hyperinsulinism (HI) is a group of rare genetic disorders characterized by dysregulated insulin secretion and is the most common cause of persistent hypoglycemia in children. Knowledge of normal glucose homeostasis allows for a better understanding of the underlying pathophysiology of hyperinsulinemic hypoglycemia, facilitating timely diagnosis and management. The goal of management is to prevent cerebral insults secondary to hypoglycemia, which can result in poor neurologic outcomes and intellectual disability. Responsiveness to diazoxide, the first-line pharmacologic therapy for persistent hypoglycemia, is also the first step to distinguishing the different genotypic causes of monogenic hyperinsulinism. Early genetic testing becomes necessary when monogenic HI is strongly considered. Knowledge of specific gene mutations allows the determination of a clinical prognosis and definite therapeutic options, such as identifying those with focal forms of hyperinsulinism, who may attain a complete cure through surgical removal of specific affected parts of the pancreas. However, the lack of identifiable cause in a considerable number of patients identified with HI suggests there may be other genetic loci that are yet to be discovered. Furthermore, continued research is needed to explore new forms of therapy, particularly in severe, diazoxide-nonresponsive cases.
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26
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Nichols CG, York NW, Remedi MS. ATP-Sensitive Potassium Channels in Hyperinsulinism and Type 2 Diabetes: Inconvenient Paradox or New Paradigm? Diabetes 2022; 71:367-375. [PMID: 35196393 PMCID: PMC8893938 DOI: 10.2337/db21-0755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/28/2021] [Indexed: 11/13/2022]
Abstract
Secretion of insulin from pancreatic β-cells is complex, but physiological glucose-dependent secretion is dominated by electrical activity, in turn controlled by ATP-sensitive potassium (KATP) channel activity. Accordingly, loss-of-function mutations of the KATP channel Kir6.2 (KCNJ11) or SUR1 (ABCC8) subunit increase electrical excitability and secretion, resulting in congenital hyperinsulinism (CHI), whereas gain-of-function mutations cause underexcitability and undersecretion, resulting in neonatal diabetes mellitus (NDM). Thus, diazoxide, which activates KATP channels, and sulfonylureas, which inhibit KATP channels, have dramatically improved therapies for CHI and NDM, respectively. However, key findings do not fit within this simple paradigm: mice with complete absence of β-cell KATP activity are not hyperinsulinemic; instead, they are paradoxically glucose intolerant and prone to diabetes, as are older human CHI patients. Critically, despite these advances, there has been little insight into any role of KATP channel activity changes in the development of type 2 diabetes (T2D). Intriguingly, the CHI progression from hypersecretion to undersecretion actually mirrors the classical response to insulin resistance in the progression of T2D. In seeking to explain the progression of CHI, multiple lines of evidence lead us to propose that underlying mechanisms are also similar and that development of T2D may involve loss of KATP activity.
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Affiliation(s)
- Colin G Nichols
- Center for the Investigation of Membrane Excitability Diseases, Washington University School of Medicine, St. Louis, MO
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, MO
| | - Nathaniel W York
- Center for the Investigation of Membrane Excitability Diseases, Washington University School of Medicine, St. Louis, MO
- Department of Cell Biology and Physiology, Washington University School of Medicine, St. Louis, MO
| | - Maria S Remedi
- Center for the Investigation of Membrane Excitability Diseases, Washington University School of Medicine, St. Louis, MO
- Division of Endocrinology Metabolism and Lipid Research, Department of Medicine, Washington University School of Medicine, St. Louis, MO
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27
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Banerjee I, Raskin J, Arnoux JB, De Leon DD, Weinzimer SA, Hammer M, Kendall DM, Thornton PS. Congenital hyperinsulinism in infancy and childhood: challenges, unmet needs and the perspective of patients and families. Orphanet J Rare Dis 2022; 17:61. [PMID: 35183224 PMCID: PMC8858501 DOI: 10.1186/s13023-022-02214-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/06/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycemia in infants and children, and carries a considerable risk of neurological damage and developmental delays if diagnosis and treatment are delayed. Despite rapid advances in diagnosis and management, long-term developmental outcomes have not significantly improved in the past years. CHI remains a disease that is associated with significant morbidity, and psychosocial and financial burden for affected families, especially concerning the need for constant blood glucose monitoring throughout patients' lives. RESULTS In this review, we discuss the key clinical challenges and unmet needs, and present insights on patients' and families' perspective on their daily life with CHI. Prevention of neurocognitive impairment and successful management of patients with CHI largely depend on early diagnosis and effective treatment by a multidisciplinary team of specialists with experience in the disease. CONCLUSIONS To ensure the best outcomes for patients and their families, improvements in effective screening and treatment, and accelerated referral to specialized centers need to be implemented. There is a need to develop a wider range of centers of excellence and networks of specialized care to optimize the best outcomes both for patients and for clinicians. Awareness of the presentation and the risks of CHI has to be raised across all professions involved in the care of newborns and infants. For many patients, the limited treatment options currently available are insufficient to manage the disease effectively, and they are associated with a range of adverse events. New therapies would benefit all patients, even those that are relatively stable on current treatments, by reducing the need for constant blood glucose monitoring and facilitating a personalized approach to treatment.
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Affiliation(s)
- Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Oxford Road, Manchester, M13 9WL, UK.
| | - Julie Raskin
- Congenital Hyperinsulinism International, Glen Ridge, NJ, USA
| | - Jean-Baptiste Arnoux
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Diva D De Leon
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Paul S Thornton
- Congenital Hyperinsulinism Center, Cook Children's Medical Center, Fort Worth, TX, USA
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28
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Lithovius V, Otonkoski T. Stem Cell Based Models in Congenital Hyperinsulinism - Perspective on Practicalities and Possibilities. Front Endocrinol (Lausanne) 2022; 13:837450. [PMID: 35250887 PMCID: PMC8895269 DOI: 10.3389/fendo.2022.837450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/27/2022] [Indexed: 12/31/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a severe inherited neonatal disorder characterized by inappropriate insulin secretion caused by genetic defects of the pancreatic beta cells. Several open questions remain in CHI research, such as the optimal treatment for the most common type of CHI, caused by mutations in the genes encoding ATP-sensitive potassium channels, and the molecular mechanisms of newly identified CHI genes. Answering these questions requires robust preclinical models, particularly since primary patient material is extremely scarce and accurate animal models are not available. In this short review, we explain why pluripotent stem cell derived islets present an attractive solution to these issues and outline the current progress in stem-cell based modeling of CHI. Stem cell derived islets enable the study of molecular mechanisms of CHI and the discovery of novel antihypoglycemic drugs, while also providing a valuable model to study the biology of variable functional states of beta cells.
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Affiliation(s)
- Väinö Lithovius
- Stem Cells and Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- *Correspondence: Väinö Lithovius, ; Timo Otonkoski,
| | - Timo Otonkoski
- Stem Cells and Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
- *Correspondence: Väinö Lithovius, ; Timo Otonkoski,
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29
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Zhang J, Wang J, Chen H. Case report: Congenital hyperinsulinemia with ABCC8 gene mutations. Front Pediatr 2022; 10:914267. [PMID: 36034573 PMCID: PMC9403267 DOI: 10.3389/fped.2022.914267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 07/28/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Congenital hyperinsulinemia (CHI) is an inherited disease of abnormal insulin secretion and is the main cause of persistent and intractable hypoglycemia in infants. The aim of this case report was to investigate the genetic mechanisms and treatment of CHI in an affected patient. CASE SUMMARY We collected clinical data from, and performed gene capture, high-throughput gene sequencing analysis, and Sanger sequencing validation, in a child with CHI and his family to identify the causative gene mutations. Two heterozygous pathogenic mutations in the ATP-binding cassette subfamily C member 8 (ABCC8) gene were detected in the child: c.863G>A (p.Trp288Ter) in exon 6 and c.2506C>T (p.Arg836Ter) in exon 21. Sanger sequencing showed that c.863G>A was inherited from heterozygous mutations in the paternal line and c.2506C>T from heterozygous mutations in the maternal line. CONCLUSION The child was a CHI with a biallelic recessive heterozygous mutations in ABCC8 resulting in impairment of its encoded ATP-sensitive potassium (KATP) channel, poor response to diazoxide treatment, and developed diabetes after subtotal pancreatectomy.
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Affiliation(s)
- Jin Zhang
- Gansu Women's and Children's Hospital, Lanzhou, China
| | - Jiyang Wang
- Institute of Systems Engineering, Macao University of Science and Technology, Macao, China
| | - Hui Chen
- Department of Endocrinology, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
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30
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Pasquini TLS, Mesfin M, Schmitt J, Raskin J. Global Registries in Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2022; 13:876903. [PMID: 35721728 PMCID: PMC9201947 DOI: 10.3389/fendo.2022.876903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital hyperinsulinism (HI) is the most frequent cause of severe, persistent hypoglycemia in newborn babies and children. There are many areas of need for HI research. Some of the most critical needs include describing the natural history of the disease, research leading to new and better treatments, and identifying and managing hypoglycemia before it is prolonged and causes brain damage or death. Patient-reported data provides a basis for understanding the day-to-day experience of living with HI. Commonly identified goals of registries include performing natural history studies, establishing a network for future product and treatment studies, and supporting patients and families to offer more successful and coordinated care. Congenital Hyperinsulinism International (CHI) created the HI Global Registry (HIGR) in October 2018 as the first global patient-powered hyperinsulinism registry. The registry consists of thirteen surveys made up of questions about the patient's experience with HI over their lifetime. An international team of HI experts, including family members of children with HI, advocates, clinicians, and researchers, developed the survey questions. HIGR is managed by CHI and advised by internationally recognized HI patient advocates and experts. This paper aims to characterize HI through the experience of individuals who live with it. This paper includes descriptive statistics on the birthing experience, hospitalizations, medication management, feeding challenges, experiences with glucose monitoring devices, and the overall disease burden to provide insights into the current data in HIGR and demonstrate the potential areas of future research. As of January 2022, 344 respondents from 37 countries consented to participate in HIGR. Parents or guardians of individuals living with HI represented 83.9% of the respondents, 15.3% were individuals living with HI. Data from HIGR has already provided insight into access challenges, patients' and caregivers' quality of life, and to inform clinical trial research programs. Data is also available to researchers seeking to study the pathophysiology of HI retrospectively or to design prospective trials related to improving HI patient outcomes. Understanding the natural history of the disease can also guide standards of care. The data generated through HIGR provides an opportunity to improve the lives of all those affected by HI.
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31
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Raskin J, Pasquini TLS, Bose S, Tallis D, Schmitt J. Congenital Hyperinsulinism International: A Community Focused on Improving the Lives of People Living With Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2022; 13:886552. [PMID: 35573986 PMCID: PMC9097272 DOI: 10.3389/fendo.2022.886552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/24/2022] [Indexed: 12/03/2022] Open
Abstract
Congenital hyperinsulinism (HI) is a rare disease affecting newborns. HI causes severe hypoglycemia due to the overproduction of insulin. The signs and symptoms of hypoglycemia in HI babies is often not discovered until brain damage has already occurred. Prolonged hypoglycemia from HI can even lead to death. Disease management is often complex with a high burden on caregivers. Treatment options are extremely limited and often require long hospital stays to devise. Cascading from suboptimal treatments and diagnostic practices are a host of other problems and challenges that many with HI and their families experience including continued fear of hypoglycemia and feeding problems. The aim of this paper is (1) to describe the current challenges of living with HI including diagnosis and disease management told from the perspective of people who live with the condition (2), to provide family stories of life with HI, and (3) to share how a rare disease patient organization, Congenital Hyperinsulinism International (CHI) is working to improve the lives of HI patients and their families. CHI is a United States based nonprofit organization with a global focus. The paper communicates the programs the patient advocacy organization has put into place to support HI families through its virtual and in-person gatherings. The organization also helps individuals access diagnostics, medical experts, and treatments. CHI also raises awareness of HI to improve patient outcomes with information about HI and prolonged hypoglycemia in twenty-three languages. CHI drives innovation for new and better treatments by funding research pilot grants, conducting research through the HI Global Registry, and providing patient experience expertise to researchers developing new treatments. The organization is also the sponsor of the CHI Collaborative Research Network which brings medical and scientific experts together for the development of a patient-focused prioritized research agenda.
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32
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Walker JT, Saunders DC, Brissova M, Powers AC. The Human Islet: Mini-Organ With Mega-Impact. Endocr Rev 2021; 42:605-657. [PMID: 33844836 PMCID: PMC8476939 DOI: 10.1210/endrev/bnab010] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Indexed: 02/08/2023]
Abstract
This review focuses on the human pancreatic islet-including its structure, cell composition, development, function, and dysfunction. After providing a historical timeline of key discoveries about human islets over the past century, we describe new research approaches and technologies that are being used to study human islets and how these are providing insight into human islet physiology and pathophysiology. We also describe changes or adaptations in human islets in response to physiologic challenges such as pregnancy, aging, and insulin resistance and discuss islet changes in human diabetes of many forms. We outline current and future interventions being developed to protect, restore, or replace human islets. The review also highlights unresolved questions about human islets and proposes areas where additional research on human islets is needed.
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Affiliation(s)
- John T Walker
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Diane C Saunders
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marcela Brissova
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Alvin C Powers
- Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
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Yang J, Hammoud B, Li C, Ridler A, Yau D, Kim J, Won KJ, Stanley CA, Hoshi T, Stanescu DE. Decreased KATP Channel Activity Contributes to the Low Glucose Threshold for Insulin Secretion of Rat Neonatal Islets. Endocrinology 2021; 162:6301135. [PMID: 34134142 PMCID: PMC8276892 DOI: 10.1210/endocr/bqab121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Indexed: 12/12/2022]
Abstract
Transitional hypoglycemia in normal newborns occurs in the first 3 days of life and has clinical features consistent with hyperinsulinism. We found a lower threshold for glucose-stimulated insulin secretion from freshly isolated embryonic day (E) 22 rat islets, which persisted into the first postnatal days. The threshold reached the adult level by postnatal day (P) 14. Culturing P14 islets also decreased the glucose threshold. Freshly isolated P1 rat islets had a lower threshold for insulin secretion in response to 2-aminobicyclo-(2, 2, 1)-heptane-2-carboxylic acid, a nonmetabolizable leucine analog, and diminished insulin release in response to tolbutamide, an inhibitor of β-cell KATP channels. These findings suggested that decreased KATP channel function could be responsible for the lower glucose threshold for insulin secretion. Single-cell transcriptomic analysis did not reveal a lower expression of KATP subunit genes in E22 compared with P14 β cells. The investigation of electrophysiological characteristics of dispersed β cells showed that early neonatal and cultured cells had fewer functional KATP channels per unit membrane area. Our findings suggest that decreased surface density of KATP channels may contribute to the observed differences in glucose threshold for insulin release.
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Affiliation(s)
- Juxiang Yang
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Batoul Hammoud
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Changhong Li
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Abigail Ridler
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Daphne Yau
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Junil Kim
- Biotech Research & Innovation Centre, University of Copenhagen, DK-2200 Copenhagen N, Denmark
- School of Systems Biomedical Science, Soongsil University, Seoul 06978, South Korea
| | - Kyoung-Jae Won
- Biotech Research & Innovation Centre, University of Copenhagen, DK-2200 Copenhagen N, Denmark
| | - Charles A Stanley
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Toshinori Hoshi
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Diana E Stanescu
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Correspondence: Diana Elena Stanescu, MD, The Children's Hospital of Philadelphia, Abramson Pediatric Research Center, 3615 Civic Center Blvd, #802G, Philadelphia, PA 19104, USA.
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34
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Nóvoa Medina Y, Domínguez García Á, Quinteiro González S, García Cruz LM, Santana Rodríguez A. Hiperinsulinismo congénito en Gran Canaria. An Pediatr (Barc) 2021. [DOI: 10.1016/j.anpedi.2020.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Herrera Azabache K, Muñoz Bermúdez Z, Ferrández Mengual D, Nso-Roca AP. Hiperinsulinismo congénito en tres pacientes de la misma familia. Ampliando el genotipo de esta enfermedad. An Pediatr (Barc) 2021. [DOI: 10.1016/j.anpedi.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Nóvoa-Medina Y, Domínguez García A, Quinteiro González S, García Cruz LM, Santana Rodríguez A. Congenital hyperinsulinism in Gran Canaria, Canary Isles. An Pediatr (Barc) 2021; 95:93-100. [PMID: 34253504 DOI: 10.1016/j.anpede.2020.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/31/2020] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Congenital hyperinsulinism (CH) is a severe disorder characterised by the appearance of severe hypoglycaemia. Pathogenic mutations in the ABCC8 and KCNJ11 genes are the most frequent cause, although its appearance also been associated to mutations in other genes (GCK, GLUD1, HADH, HNF1A, HNF4A, SLC16A1, UCP2, HK1), and with different syndromes. MATERIALS AND METHODS Retrospective review of patients diagnosed with CH in this unit during the last 18 years (2001-2018). Genetic analysis included screening for 11 genes in genomic DNA from peripheral blood (ABCC8, GCK, GLUD1, HADH, HNF1A, HNF4A, INSR, KCNJ11, SLC16A1, UCP2, and SLC25A15). OBJECTIVE To carry out a clinical and genetic characterisation of the diagnosed cases of CH in Gran Canaria. RESULTS There have been 10 cases of persistent HC since 2001. Seven of them had mutations in the ABCC8 gene, one in the HNF4α gene, and in two patients, no pathogenic mutations were found in the analysed genes. Four patients presented with previously undescribed mutations. Pancreatectomy was performed in two of the cases. The minimum insulin value detected in hypoglycaemia was 6.81 µIU/mL. The incidence of persistent CH for Gran Canaria and Lanzarote is 1/15,614. CONCLUSIONS Four patients had previously undescribed mutations. The most frequently affected gene was ABCC8. Pancreatectomy was required in 20% of the patients. An insulin value of ≥6.81 µIU/mL was observed in all patients at the time of diagnosis. The incidence of CH in Gran Canaria is high.
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Affiliation(s)
- Yeray Nóvoa-Medina
- Unidad de Endocrinología Pediátrica, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain; Asociación Canaria para la Investigación Pediátrica (ACIP Canarias), Las Palmas de Gran Canaria, Spain.
| | - Angela Domínguez García
- Unidad de Endocrinología Pediátrica, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Sofía Quinteiro González
- Unidad de Endocrinología Pediátrica, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Loida María García Cruz
- Unidad de Genética Clínica, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | - Alfredo Santana Rodríguez
- Unidad de Genética Clínica, Complejo Hospitalario Universitario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
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Djekidel M. 18F-FDOPA and 68Ga-dotatate PET imaging in congenital hyperinsulinism. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2021; 11:188-195. [PMID: 34234997 PMCID: PMC8255214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/07/2021] [Indexed: 06/13/2023]
Abstract
Congenital hyperinsulinism (CHI) occurs most commonly in infants but may also be discovered in older children. It presents with recurrent episodes of hypoglycemia due to high endogenous insulin levels. There is a focal and diffuse form of the disease depending on the extent of pancreatic involvement. Hyperplasia of the islet cells results in hyperfunctioning pancreatic β cells and the ensuing clinical disease. Medical treatment fails in several patients and surgery has been shown to be very effective in improving prognosis and even resolution of disease in the focal form. Several genetic mutations have been uncovered and these may also be predictive of prognosis. Anatomical imaging alone including ultrasound, CT and MRI are rarely able to detect any abnormality in the pancreas. PET plays a major role in the distinction between the focal and diffuse forms of the disease. It also guides surgical intervention by providing information on the location of the focal hyperfunctioning islet cells. Imaging children and infants in this disease is quite challenging. We propose to show the benefit of using two PET tracers in this disease. 18F-FDOPA has been used quite successfully in the evaluation of CHI. 68Ga-DOTATATE has also been described to be helpful although inferior to 18F-FDOPA. We illustrate imaging of CHI patients in 3 different scans and briefly review the literature. 18F-FDOPA as described in the literature is superior but when unavailable 68Ga-DOTATATE may be a reasonable alternative.
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Affiliation(s)
- Mehdi Djekidel
- Division Lead Nuclear Medicine and Molecular Imaging, Department of Diagnostic Imaging, Sidra Medicine Al-Luqta Street, PO Box Number. 26999, Doha, Qatar
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Descamps J, Ruello C, Perge K, de Bellescize J, Saint-Martin C, Nicolino M. Epileptic phenotype in late-onset hyperinsulinemic hypoglycemia successfully treated by diazoxide. J Pediatr Endocrinol Metab 2021; 34:667-673. [PMID: 33662190 DOI: 10.1515/jpem-2020-0381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 12/08/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Serious hyperinsulinemic hypoglycemia (HH) is generally the main initial symptom of hyperinsulinism. Epilepsy, without any overt feature of hypoglycemia, might be a very rare initial presentation of late-onset isolated hyperinsulinism. CASE PRESENTATION We describe a case of late-onset HH in a 15-year-old boy with a history of idiopathic generalized epilepsy, now named genetic generalized epilepsy (IGE/GGE), beginning with a tonic-clonic seizure at the age of 11 years. Subsequently, absences with rare eyelid myoclonia were recorded on electroencephalogram (EEG), followed by episodes of impaired consciousness with facial myoclonia. Neurological status was normal except attention-deficit hyperactivity disorder (ADHD). At the age of 15 years, an episode of slight alteration of consciousness with neurovegetative signs could be recorded, which did not correspond to an absence status. Hypoglycemia due to hyperinsulinism was documented (clinically, biologically, and genetically). Diazoxide treatment resolved the glycopenic symptoms, the non-hypoglycemic seizures and normalized brain electrical activity allowing complete withdrawal of antiepileptic medication. CONCLUSIONS Epilepsy can be a very rare initial feature of HH starting in childhood. The occurrence of atypical features in the context of GGE as "absence statuses" with unusual vegetative symptoms and facial myoclonia might be suggestive for HH. Careful assessment and specific treatment are necessary to prevent hyperinsulinism related brain damage. Our case showed that diazoxide might also resolve seizures and normalize EEG.
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Affiliation(s)
- Justine Descamps
- Department of Pediatric Endocrinology, HFME, Hospices Civils de Lyon, Bron, France
| | - Cyril Ruello
- Department of Pediatric Endocrinology, HFME, Hospices Civils de Lyon, Bron, France
| | - Kevin Perge
- Department of Pediatric Endocrinology, HFME, Hospices Civils de Lyon, Bron, France
| | - Julitta de Bellescize
- Department of Epileptology, Sleep Disorders and Functional Pediatric Neurology, HFME, Hospices Civils de Lyon, Bron, France
| | | | - Marc Nicolino
- Department of Pediatric Endocrinology, HFME, Hospices Civils de Lyon, Bron, France.,Faculty of Medicine, Claude-Bernard Lyon 1 University, Lyon, France
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Herrera Azabache K, Muñoz Bermúdez Z, Ferrández Mengual D, Nso-Roca AP. Congenital hyperinsulinism in three patients from the same family. Expanding the genotype of this disease. An Pediatr (Barc) 2021; 95:123-124. [PMID: 34373074 DOI: 10.1016/j.anpede.2020.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/10/2020] [Indexed: 10/21/2022] Open
Affiliation(s)
| | | | | | - Ana Pilar Nso-Roca
- Endocrinología Infantil. Hospital Universitario San Juan de Alicante, Alicante, Spain.
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40
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Wild KT, Nomakuchi TT, Sheppard SE, Leavens KF, De León DD, Zackai EH. Hyperinsulinism in an individual with an EP300 variant of Rubinstein-Taybi syndrome. Am J Med Genet A 2021; 185:1251-1255. [PMID: 33442921 PMCID: PMC8621558 DOI: 10.1002/ajmg.a.62085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 01/01/2021] [Accepted: 01/03/2021] [Indexed: 01/21/2023]
Abstract
Rubinstein-Taybi syndrome (RSTS) is an autosomal dominant genetic syndrome characterized by distinct facial features, broad thumbs, growth restriction, microcephaly, intellectual disability, and developmental delay. Pathogenic variants in both CREBBP and EP300 have been associated with RSTS. Here we present a case of a female with hyperinsulinism and features consistent with RSTS, found to have a pathogenic variant in EP300. While there have been a few rare case reports of hyperinsulinism in RSTS, we suggest that hyperinsulinism might be a more prominent feature in EP300 variant RSTS than previously recognized.
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Affiliation(s)
- K. Taylor Wild
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Tomoki T. Nomakuchi
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah E. Sheppard
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Center for Applied Genomics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Karla F. Leavens
- Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Diva D. De León
- Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania,Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elaine H. Zackai
- Division of Human Genetics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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41
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Männistö JME, Jääskeläinen J, Otonkoski T, Huopio H. Long-Term Outcome and Treatment in Persistent and Transient Congenital Hyperinsulinism: A Finnish Population-Based Study. J Clin Endocrinol Metab 2021; 106:e1542-e1551. [PMID: 33475139 PMCID: PMC7993590 DOI: 10.1210/clinem/dgab024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT The management of congenital hyperinsulinism (CHI) has improved. OBJECTIVE To examine the treatment and long-term outcome of Finnish patients with persistent and transient CHI (P-CHI and T-CHI). DESIGN A population-based retrospective study of CHI patients treated from 1972 to 2015. PATIENTS 106 patients with P-CHI and 132 patients with T-CHI (in total, 42 diagnosed before and 196 after year 2000) with median follow-up durations of 12.5 and 6.2 years, respectively. MAIN OUTCOME MEASURES Recovery, diabetes, pancreatic exocrine dysfunction, neurodevelopment. RESULTS The overall incidence of CHI (n = 238) was 1:11 300 live births (1972-2015). From 2000 to 2015, the incidence of P-CHI (n = 69) was 1:13 500 and of T-CHI (n = 127) 1:7400 live births. In the 21st century P-CHI group, hyperinsulinemic medication was initiated and normoglycemia achieved faster relative to earlier. Of the 74 medically treated P-CHI patients, 68% had discontinued medication. Thirteen (12%) P-CHI patients had partial pancreatic resection and 19 (18%) underwent near-total pancreatectomy. Of these, 0% and 84% developed diabetes and 23% and 58% had clinical pancreatic exocrine dysfunction, respectively. Mild neurological difficulties (21% vs 16%, respectively) and intellectual disability (9% vs 5%, respectively) were as common in the P-CHI and T-CHI groups. However, the 21st century P-CHI patients had significantly more frequent normal neurodevelopment and significantly more infrequent diabetes and pancreatic exocrine dysfunction compared with those diagnosed earlier. CONCLUSIONS Our results demonstrated improved treatment and long-term outcome in the 21st century P-CHI patients relative to earlier.
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Affiliation(s)
- Jonna M E Männistö
- Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
- Correspondence: Jonna Männistö, MD, Department of Pediatrics, Kuopio University Hospital, P.O. Box 100, FI-70029 KYS, Kuopio, Finland.
| | - Jarmo Jääskeläinen
- Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Timo Otonkoski
- Children’s Hospital and Stem Cells and Metabolism Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Huopio
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
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42
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Liu Q, Garg P, Hasdemir B, Wang L, Tuscano E, Sever E, Keane E, Hernandez AGL, Yuan TZ, Kwan E, Lai J, Szot G, Paruthiyil S, Axelrod F, K. Sato A. Functional GLP-1R antibodies identified from a synthetic GPCR-focused library demonstrate potent blood glucose control. MAbs 2021; 13:1893425. [PMID: 33706686 PMCID: PMC7971233 DOI: 10.1080/19420862.2021.1893425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 02/04/2021] [Accepted: 02/17/2021] [Indexed: 11/15/2022] Open
Abstract
G protein-coupled receptors (GPCRs) are a group of seven-transmembrane receptor proteins that have proven to be successful drug targets. Antibodies are becoming an increasingly promising modality to target these receptors due to their unique properties, such as exquisite specificity, long half-life, and fewer side effects, and their improved pharmacokinetic and pharmacodynamic profiles compared to peptides and small molecules, which results from their more favorable biodistribution. To date, there are only two US Food and Drug Administration-approved GPCR antibody drugs, namely erenumab and mogamulizumab, and this highlights the challenges encountered in identifying functional antibodies against GPCRs. Utilizing Twist's precision DNA writing technologies, we have created a GPCR-focused phage display library with 1 × 1010 diversity. Specifically, we mined endogenous GPCR binding ligand and peptide sequences and incorporated these binding motifs into the heavy chain complementarity-determining region 3 in a synthetic antibody library. Glucagon-like peptide-1 receptor (GLP-1 R) is a class B GPCR that acts as the receptor for the incretin GLP-1, which is released to regulate insulin levels in response to food intake. GLP-1 R agonists have been widely used to increase insulin secretion to lower blood glucose levels for the treatment of type 1 and type 2 diabetes, whereas GLP-1 R antagonists have applications in the treatment of severe hypoglycemia associated with bariatric surgery and hyperinsulinomic hypoglycemia. Here we present the discovery and creation of both antagonistic and agonistic GLP-1 R antibodies by panning this GPCR-focused phage display library on a GLP-1 R-overexpressing Chinese hamster ovary cell line and demonstrate their in vitro and in vivo functional activity.
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Affiliation(s)
- Qiang Liu
- Twist Biopharma, South San Francisco, CA, USA
| | - Pankaj Garg
- Twist Biopharma, South San Francisco, CA, USA
- Alamar Biosciences, Fremont, CA, USA
| | - Burcu Hasdemir
- Twist Biopharma, South San Francisco, CA, USA
- Catalyst Biosciences, South San Francisco, CA, USA
| | - Linya Wang
- Twist Biopharma, South San Francisco, CA, USA
| | | | - Emily Sever
- Twist Biopharma, South San Francisco, CA, USA
| | - Erica Keane
- Twist Biopharma, South San Francisco, CA, USA
| | | | - Tom Z. Yuan
- Twist Biopharma, South San Francisco, CA, USA
| | - Eric Kwan
- Twist Biopharma, South San Francisco, CA, USA
| | - Joyce Lai
- Twist Biopharma, South San Francisco, CA, USA
| | - Greg Szot
- Diabetes Center, University of California San Francisco, San Francisco, CA, USA
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43
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Ros-Pérez P, Golmayo L, Cilleruelo ML, Gutiérrez C, Celaya P, Lacámara N, Martínez-Badás I, Güemes M, Argente J. Octreotide-related exocrine pancreatic insufficiency (EPI) in congenital hyperinsulinism. J Pediatr Endocrinol Metab 2020; 33:947-950. [PMID: 32634108 DOI: 10.1515/jpem-2019-0565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/09/2020] [Indexed: 12/22/2022]
Abstract
Background Congenital hyperinsulinism (CH) is the most frequent cause of persistent hypoglycemia in the newborn. Octreotide, a long-acting somatostatin receptor analog (SSRA), is a second line treatment for diazoxide unresponsive CH patients. Although it has been found to be a safe and effective treatment, long-term benefits and side effects, have not been thoroughly evaluated. Case presentation Some authors have indicated that exocrine pancreatic insufficiency (EPI) is a common but under-recognized adverse reaction in adults treated with octreotide. However, no pediatric patient with SSRA-induced EPI has been reported to date. Here we report a case of an infant with diazoxide unresponsive, diffuse CH, caused by a heterozygous pathogenic paternally inherited mutation in the ABCC8 gene (NM_000352.4:c.357del), that developed exocrine pancreatic insufficiency and secondary vitamin K deficiency associated to chronic octreotide therapy. Conclusions We point out the atypical clinical onset with a cutaneous hemorrhagic syndrome, emphasizing the clinical relevance of this potential side effect.
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Affiliation(s)
- Purificación Ros-Pérez
- Department of Pediatrics, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
- Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain
| | - Luz Golmayo
- Department of Pediatrics, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - María L Cilleruelo
- Department of Pediatrics, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
- Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carolina Gutiérrez
- Department of Pediatrics, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
- Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain
| | - Patricia Celaya
- Department of Pediatrics, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Nerea Lacámara
- Department of Pediatrics, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - Itziar Martínez-Badás
- Department of Pediatrics, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | - María Güemes
- Department of Endocrinology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
- Centro de Investigación Biomédica en Red de obesidad y nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Jesús Argente
- Department of Pediatrics, Universidad Autónoma de Madrid, Madrid, Spain
- Department of Endocrinology, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
- Centro de Investigación Biomédica en Red de obesidad y nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
- Instituto de Investigación la Princesa, Madrid, Spain
- IMDEA Food Institute, Campus of International Excellence (CEI) UAM + CSIC, Madrid, Spain
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Worth C, Yau D, Salomon Estebanez M, O'Shea E, Cosgrove K, Dunne M, Banerjee I. Complexities in the medical management of hypoglycaemia due to congenital hyperinsulinism. Clin Endocrinol (Oxf) 2020; 92:387-395. [PMID: 31917867 DOI: 10.1111/cen.14152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 12/12/2022]
Abstract
Congenital Hyperinsulinism (CHI) is a rare disease of hypoglycaemia but is the most common form of recurrent and severe hypoglycaemia causing brain injury and neurodisability in children. The management of CHI is complex due to the limited choice of medications, all with a limited therapeutic window, often lacking efficacy and associated with serious side effects. The therapeutic strategy in CHI is to recognize and treat hypoglycaemia promptly, thereby optimizing long-term neurological outcomes; this should be achieved through individualized treatment plans that deliver glycaemic stability while minimizing side effects. Further, such a strategy should consider the likelihood of reduction in disease severity over time, with dose adjustments and medication withdrawal as indicated to optimize both safety and tolerability. The option for pancreatic surgery should also be considered in specific circumstances as appropriate for the patient's best long-term interests.
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Affiliation(s)
- Christopher Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Daphne Yau
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Department of Pediatrics, Division of Endocrinology, Jim Pattison Children's Hospital, Saskatoon, SK, Canada
| | - Maria Salomon Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Elaine O'Shea
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Karen Cosgrove
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mark Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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Burkardt DD, Tatton-Brown K, Dobyns W, Graham JM. Approach to overgrowth syndromes in the genome era. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 181:483-490. [PMID: 31793186 DOI: 10.1002/ajmg.c.31757] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 11/05/2019] [Indexed: 12/15/2022]
Abstract
This introduction to the special issue of AJMG Part C: Overgrowth Syndromes updates the current understanding of overgrowth syndromes. We clarify the terminology associated with overgrowth, review some common pathways to overgrowth and present a preliminary classification based on currently known genomic and epigenetic mechanisms. We introduce the articles of this issue-new research and reviews of well-established and recently described overgrowth syndromes of the brain, body or both.
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Affiliation(s)
| | - Katrina Tatton-Brown
- South West Thames Regional Genetics Service, St George's University Hospitals NHS Foundation Trust, London, UK.,St George's University of London, London, UK.,Institute of Cancer Research, Surrey, UK
| | - William Dobyns
- Department of Pediatrics and Neurology, University of Washington School of Medicine, and Center for Integrative Brain Research, Seattle Children's Hospital, Seattle, Washington
| | - John M Graham
- Division of Medical Genetics, Cedars-Sinai Medical Center, Los Angeles, California
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Rayannavar A, Elci OU, Mitteer L, De Leon DD. Continuous Glucose Monitoring Systems: Are They Useful for Evaluating Glycemic Control in Children with Hyperinsulinism? Horm Res Paediatr 2019; 92:319-327. [PMID: 32208390 PMCID: PMC7192768 DOI: 10.1159/000506230] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 01/28/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Effective treatment and close monitoring in children with congenital hyperinsulinism (HI) are important to prevent hypoglycemic-associated brain damage. The current monitoring approach involves measuring plasma glucose intermittently, but this does not provide a comprehensive assessment of glycemic control and may fail to detect episodes of hypoglycemia. OBJECTIVE To determine whether Dexcom G5®, a continuous glucose monitoring system (CGMS), is an accurate and effective method for monitoring glycemic control in children with HI. METHODS Cross-sectional, observational study in 15 children with HI. Participants wore a blinded Dexcom G5® device for 2 weeks. At the end of 2 weeks, data from the Dexcom G5® and home glucose meter were downloaded and analyzed. RESULTS Fourteen children (15-67 months) completed the study. Using Bland-Altman analysis, the mean (SD) difference between 1,155 paired CGM and glucose meter readings was -8.09 (53.76). The sensitivity and specificity of CGM to detect hypoglycemia (<70 mg/dL) were 86 and 81.4%, respectively. The positive predictive values for hypoglycemia and severe hypoglycemia (<54 mg/dL) detected by CGM were low (50.3 and 14.8%, respectively), while the negative predictive values were high (96.4% for glucose <70 mg/dL and 99.1% for glucose <54 mg/dL). CONCLUSION Our study showed that CGM is not a reliable method to monitor for hypoglycemia, given the high number of false positive hypoglycemia readings. However, CGM can be useful in preventing unnecessary checks by glucose meter during times of normoglycemia. Therefore, the benefits of using CGM in patients with HI would be in guiding the need to check plasma glucose by glucose meter rather than point accuracy.
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Affiliation(s)
- Arpana Rayannavar
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Okan U. Elci
- Westat, Rockville MD,Biostatistics and Data Management Core, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Lauren Mitteer
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Diva D. De Leon
- Division of Endocrinology and Diabetes, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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