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Wu M, Davis JD, Zhao C, Daley T, Oliver KE. Racial inequities and rare CFTR variants: Impact on cystic fibrosis diagnosis and treatment. J Clin Transl Endocrinol 2024; 36:100344. [PMID: 38765466 PMCID: PMC11099334 DOI: 10.1016/j.jcte.2024.100344] [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: 12/14/2023] [Revised: 02/21/2024] [Accepted: 04/14/2024] [Indexed: 05/22/2024] Open
Abstract
Cystic fibrosis (CF) has been traditionally viewed as a disease that affects White individuals. However, CF occurs among all races, ethnicities, and geographic ancestries. The disorder results from mutations in the CF transmembrane conductance regulator (CFTR). Varying incidence of CF is reported among Black, Indigenous, and People of Color (BIPOC), who typically exhibit worse clinical outcomes. These populations are more likely to carry rare CFTR variants omitted from newborn screening panels, leading to disparities in care such as delayed diagnosis and treatment. In this study, we present a case-in-point describing an individual of Gambian descent identified with CF. Patient genotype includes a premature termination codon (PTC) (c.2353C>T) and previously undescribed single nucleotide deletion (c.1970delG), arguing against effectiveness of currently available CFTR modulator-based interventions. Strategies for overcoming these two variants will likely include combinations of PTC suppressors, nonsense mediated decay inhibitors, and/or alternative approaches (e.g. gene therapy). Investigations such as the present study establish a foundation from which therapeutic treatments may be developed. Importantly, c.2353C>T and c.1970delG were not detected in the patient by traditional CFTR screening panels, which include an implicit racial and ethnic diagnostic bias as these tests are comprised of mutations largely observed in people of European ancestry. We suggest that next-generation sequencing of CFTR should be utilized to confirm or exclude a CF diagnosis, in order to equitably serve BIPOC individuals. Additional epidemiologic data, basic science investigations, and translational work are imperative for improving understanding of disease prevalence and progression, CFTR variant frequency, genotype-phenotype correlation, pharmacologic responsiveness, and personalized medicine approaches for patients with African ancestry and other historically understudied geographic lineages.
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Affiliation(s)
- Malinda Wu
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Jacob D. Davis
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | - Conan Zhao
- Interdisciplinary Graduate Program in Quantitative Biosciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - Tanicia Daley
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Kathryn E. Oliver
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
- Pediatric Institute, Children’s Healthcare of Atlanta, Atlanta, GA, USA
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Anton-Păduraru DT, Murgu AM, Donos MA, Trofin F, Azoicăi AN, Popovici P, Stana AB, Gheorghiescu I, Trandafir LM. An Update in Cystic Fibrosis-Related Diabetes in Children and Adolescents. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1879. [PMID: 38136081 PMCID: PMC10741586 DOI: 10.3390/children10121879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/21/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
This paper delineates several aspects of cystic fibrosis-related diabetes (CFRD)-a common complication of cystic fibrosis (CF). CFRD exhibits a predilection for older individuals with CF, yet it also extends its influence on children and adolescents. Scientific insights postulate a potential link between CFRD and the aberrant mucus production within the pancreas, thereby culminating in pancreatic insufficiency. This, in turn, perturbs the synthesis of insulin, a pivotal endocrine hormone responsible for the regulation of glycemic levels. Standardized protocols advocate for the systematic screening of CFRD among all individuals with CF, commencing at the age of 10 years using the oral glucose tolerance test (OGTT). Therapeutic modalities encompass insulin therapy, dietary adjustments, and the vigilant monitoring of glycemic parameters. The overarching objective is to maintain blood glucose levels within a targeted range to mitigate the advent of diabetic complications. Untreated or sub-optimally managed CFRD can precipitate a spectrum of deleterious health ramifications, encompassing cardiovascular afflictions, neuropathy, renal dysfunction, and ocular complications.
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Affiliation(s)
- Dana-Teodora Anton-Păduraru
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.-T.A.-P.); (A.M.M.); (A.N.A.); (P.P.); (A.B.S.); (L.M.T.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
| | - Alina Mariela Murgu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.-T.A.-P.); (A.M.M.); (A.N.A.); (P.P.); (A.B.S.); (L.M.T.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
| | - Mădălina Andreea Donos
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.-T.A.-P.); (A.M.M.); (A.N.A.); (P.P.); (A.B.S.); (L.M.T.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
| | - Felicia Trofin
- Department of Preventive Medicine and Interdisciplinarity—Microbiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
- Clinical Hospital of Infectious Diseases “Sf. Parascheva”, 700116 Iasi, Romania
| | - Alice Nicoleta Azoicăi
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.-T.A.-P.); (A.M.M.); (A.N.A.); (P.P.); (A.B.S.); (L.M.T.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
| | - Paula Popovici
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.-T.A.-P.); (A.M.M.); (A.N.A.); (P.P.); (A.B.S.); (L.M.T.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
| | - Aurelian Bogdan Stana
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.-T.A.-P.); (A.M.M.); (A.N.A.); (P.P.); (A.B.S.); (L.M.T.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
| | - Ionela Gheorghiescu
- Faculty of General Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Laura Mihaela Trandafir
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (D.-T.A.-P.); (A.M.M.); (A.N.A.); (P.P.); (A.B.S.); (L.M.T.)
- “Sf. Maria” Children Emergency Hospital, 700309 Iasi, Romania
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3
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Kumar S, Soldatos G, Teede HJ, Pallin M. Effects of modulator therapies on endocrine complications in adults with cystic fibrosis: a narrative review. Med J Aust 2023; 219:496-502. [PMID: 37839059 DOI: 10.5694/mja2.52119] [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: 06/05/2023] [Accepted: 09/04/2023] [Indexed: 10/17/2023]
Abstract
Cystic fibrosis is a monogenic disorder caused by mutations in the cystic fibrosis transmembrane conductance regulator (CFTR) protein, which transports chloride ions in secretory organs. Modulator therapies are small molecules that correct CFTR dysfunction and can lead to a wide range of benefits for both pulmonary and extrapulmonary complications of cystic fibrosis. With advancements in airway, antimicrobial and nutritional therapies and now introduction of modulator therapies, most people living with cystic fibrosis in Australia are now adults. For adults with cystic fibrosis, endocrine manifestations such as cystic fibrosis-related diabetes, metabolic bone disease, and reproductive health are becoming increasingly important, and emerging evidence on the endocrine effects of CFTR modulator therapies is promising and is shifting paradigms in our understanding and management of these conditions. The management of cystic fibrosis-related diabetes will likely need to pivot for high responders to modulator therapy with dietary adaptions and potential use of medications traditionally reserved for adults with type 2 diabetes, but evidence to support changing clinical care needs is currently lacking. Increased attention to diabetes-related complications screening will also be required. Increased exercise capacity due to improved lung function, nutrition and potentially direct modulator effect may have a positive impact on cystic fibrosis-related bone disease, but supporting evidence to date is limited. Fertility can improve in women with cystic fibrosis taking modulator therapy. This has important implications for pregnancy and lactation, but evidence is lacking to guide pre-conception and antenatal management. Provision of multidisciplinary clinical care remains ever-important to ensure the emergence of endocrine and metabolic complications are optimised in adults with cystic fibrosis.
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Affiliation(s)
- Shanal Kumar
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC
- Adult Cystic Fibrosis Centre, Prince Charles Hospital, Brisbane, QLD
| | - Georgia Soldatos
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC
- Monash Health, Melbourne, VIC
| | - Helena J Teede
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC
- Monash Health, Melbourne, VIC
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Lurquin F, Buysschaert M, Preumont V. Advances in cystic fibrosis-related diabetes: Current status and future directions. Diabetes Metab Syndr 2023; 17:102899. [PMID: 37939435 DOI: 10.1016/j.dsx.2023.102899] [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: 05/31/2023] [Revised: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 11/10/2023]
Abstract
AIMS The aim of this review is to give an update of the recent advances in the pathophysiology, prognosis, diagnosis and treatments of cystic fibrosis-related diabetes (CFRD). METHODS The literature survey focuses on original and review articles dealing with CFRD between 2006 and 2023, and in particular with: pathophysiology, risk and predictive factors, screening, chronic complications of CFRD, management and the effects of CFTR channel modulator therapies on glucose homeostasis, using PubMed®. RESULTS The rising prevalence of CFRD is due to prolonged life survival among patients with cystic fibrosis (CF). Advances in the understanding of the pathophysiology highlight the singularity of CFRD. Adherence to diagnostic guidelines remains challenging. Besides the classical OGTT, alternative diagnostic tests are being considered: HbA1c measurement, continuous glucose monitoring (CGM), intermediate measurements of alternative glucose tolerance stages through OGTT and homeostatic model assessment (HOMA). Early treatment of (pre)diabetes in CF patients is mandatory. The advent of CFTR channel modulator therapies have created a paradigm shift in the management of CF: they seem to improve glucose homeostasis, but the mechanism remains unclear. CONCLUSION CFRD management is an ongoing concern. Optimal care has reduced the negative impact of CFRD on lung function, nutrition, and survival. Increasing prevalence of CFRD and prolonged lifespan lead to more microvascular complications. New screening tools (Hba1c, CGM, HOMA) show potential for better classification of patients. The effect of CFTR modulators on glucose metabolism warrants further research.
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Affiliation(s)
- F Lurquin
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium.
| | - M Buysschaert
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - V Preumont
- Department of Endocrinology and Nutrition, Cliniques Universitaires Saint-Luc, Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
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Mésinèle J, Ruffin M, Guillot L, Corvol H. Modifier Factors of Cystic Fibrosis Phenotypes: A Focus on Modifier Genes. Int J Mol Sci 2022; 23:ijms232214205. [PMID: 36430680 PMCID: PMC9698440 DOI: 10.3390/ijms232214205] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022] Open
Abstract
Although cystic fibrosis (CF) is recognized as a monogenic disease, due to variants within the CFTR (Cystic Fibrosis Transmembrane Regulator) gene, an extreme clinical heterogeneity is described among people with CF (pwCF). Apart from the exocrine pancreatic status, most studies agree that there is little association between CFTR variants and disease phenotypes. Environmental factors have been shown to contribute to this heterogeneity, accounting for almost 50% of the variability of the lung function of pwCF. Nevertheless, pwCF with similar CFTR variants and sharing the same environment (such as in siblings) may have highly variable clinical manifestations not explained by CFTR variants, and only partly explained by environmental factors. It is recognized that genetic variants located outside the CFTR locus, named "modifier genes", influence the clinical expression of the disease. This short review discusses the latest studies that have described modifier factors associated with the various CF phenotypes as well as the response to the recent CFTR modulator therapies.
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Affiliation(s)
- Julie Mésinèle
- Sorbonne Université, Inserm U938, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France
- Inovarion, 75005 Paris, France
| | - Manon Ruffin
- Sorbonne Université, Inserm U938, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France
| | - Loïc Guillot
- Sorbonne Université, Inserm U938, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France
- Correspondence: (L.G.); (H.C.)
| | - Harriet Corvol
- Sorbonne Université, Inserm U938, Centre de Recherche Saint-Antoine (CRSA), 75012 Paris, France
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Trousseau, Service de Pneumologie Pédiatrique, 75012 Paris, France
- Correspondence: (L.G.); (H.C.)
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Aksit MA, Ling H, Pace RG, Raraigh KS, Onchiri F, Faino AV, Pagel K, Pugh E, Stilp AM, Sun Q, Blue EE, Wright FA, Zhou YH, Bamshad MJ, Gibson RL, Knowles MR, Cutting GR, Blackman SM. Pleiotropic modifiers of age-related diabetes and neonatal intestinal obstruction in cystic fibrosis. Am J Hum Genet 2022; 109:1894-1908. [PMID: 36206743 PMCID: PMC9606479 DOI: 10.1016/j.ajhg.2022.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023] Open
Abstract
Individuals with cystic fibrosis (CF) develop complications of the gastrointestinal tract influenced by genetic variants outside of CFTR. Cystic fibrosis-related diabetes (CFRD) is a distinct form of diabetes with a variable age of onset that occurs frequently in individuals with CF, while meconium ileus (MI) is a severe neonatal intestinal obstruction affecting ∼20% of newborns with CF. CFRD and MI are slightly correlated traits with previous evidence of overlap in their genetic architectures. To better understand the genetic commonality between CFRD and MI, we used whole-genome-sequencing data from the CF Genome Project to perform genome-wide association. These analyses revealed variants at 11 loci (6 not previously identified) that associated with MI and at 12 loci (5 not previously identified) that associated with CFRD. Of these, variants at SLC26A9, CEBPB, and PRSS1 associated with both traits; variants at SLC26A9 and CEBPB increased risk for both traits, while variants at PRSS1, the higher-risk alleles for CFRD, conferred lower risk for MI. Furthermore, common and rare variants within the SLC26A9 locus associated with MI only or CFRD only. As expected, different loci modify risk of CFRD and MI; however, a subset exhibit pleiotropic effects indicating etiologic and mechanistic overlap between these two otherwise distinct complications of CF.
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Affiliation(s)
- Melis A Aksit
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Hua Ling
- Department of Genetic Medicine, Center for Inherited Disease Research, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Rhonda G Pace
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Karen S Raraigh
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Frankline Onchiri
- Children's Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Anna V Faino
- Children's Core for Biostatistics, Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, WA 98101, USA
| | - Kymberleigh Pagel
- The Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD 21218, USA
| | - Elizabeth Pugh
- Department of Genetic Medicine, Center for Inherited Disease Research, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Adrienne M Stilp
- Department of Biostatistics, University of Washington, Seattle, WA 98195, USA
| | - Quan Sun
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Elizabeth E Blue
- Department of Medicine, Division of Medical Genetics, University of Washington, Seattle, WA 98195, USA; Brotman Baty Institute for Precision Medicine, Seattle, WA 98195, USA
| | - Fred A Wright
- Department of Statistics, North Carolina State University, Raleigh, NC 27797, USA; Bioinformatics Research Center, North Carolina State University, Raleigh, NC 27797, USA; Department of Biological Sciences, North Carolina State University, Raleigh, NC 27797, USA
| | - Yi-Hui Zhou
- Bioinformatics Research Center, North Carolina State University, Raleigh, NC 27797, USA
| | - Michael J Bamshad
- Brotman Baty Institute for Precision Medicine, Seattle, WA 98195, USA; Department of Pediatrics, Division of Genetic Medicine, University of Washington, Seattle, WA 98195, USA; Department of Genome Sciences, University of Washington, Seattle, WA 98195, USA; Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, WA 98105, USA
| | - Ronald L Gibson
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, WA 98105, USA; Department of Pediatrics, Division of Pulmonary & Sleep Medicine, University of Washington School of Medicine/Seattle Children's Hospital, Seattle, WA, USA
| | - Michael R Knowles
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Garry R Cutting
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Scott M Blackman
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Prentice BJ, Potter KJ, Coriati A, Boudreau V, Rusnell L, Kherani T, Senior PA, Hameed S, Rabasa-Lhoret R. Cystic Fibrosis-Related Diabetes: Clinical approach and knowledge gaps. Paediatr Respir Rev 2022:S1526-0542(22)00067-7. [PMID: 36376223 DOI: 10.1016/j.prrv.2022.10.001] [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: 08/10/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022]
Abstract
Cystic Fibrosis-Related Diabetes (CFRD) is a unique type of diabetes mellitus that shares some features with both type 1 and type 2 diabetes. Yet, its distinguishing feature of acute pulmonary complications associated with hyperglycemia and the catabolic metabolism associated with a relative insulin deficiency poses challenges to the application of traditional definitions and treatments for diabetes mellitus. People with CF (pwCF) undergo rigorous annual screening starting at age 10, a process that is challenging for patients and limited by sensitivity, specificity, and reproducibility. As pwCF continue to live longer, over 50% are expected to develop CFRD over their lifetime, including up to 20% of adolescents. Increasing numbers of people with CFRD will make this disease increasingly relevant to diabetes practitioners. Evidence-guided practice in CFRD care is limited by small and short studies. Our current understanding of CFRD may change significantly with the recent introduction of CF Transmembrane Regulator (CFTR) modulator medications. This review will explore current challenges in the diagnosis and management of CFRD, specifically highlighting knowledge gaps in the pathophysiology of CFRD, optimal screening methods, priorities for research and provide guidance with regards to screening, diagnosis, and treatment.
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Affiliation(s)
- Bernadette J Prentice
- Discipline of Pediatrics, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia; Respiratory Department, Sydney Children's Hospital, Randwick, Sydney, New South Wales, Australia
| | - Kathryn J Potter
- Montreal Clinical Research Institute (IRCM), Montréal, Québec, Canada
| | - Adèle Coriati
- Montreal Clinical Research Institute (IRCM), Montréal, Québec, Canada
| | - Valérie Boudreau
- Montreal Clinical Research Institute (IRCM), Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Leah Rusnell
- Department of Pediatric Respirology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Tamizan Kherani
- Department of Pediatric Respirology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Peter A Senior
- Alberta Diabetes Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Shihab Hameed
- School of Women's and Children's Health, University of New South Wales, Sydney, Randwick, Australia; Faculty of Medicine, University of Sydney, Sydney, Australia; Dept of Endocrinology, Sydney Children's Hospital, Randwick, Australia; Dept of Paediatric Endocrinology Royal North Shore Hospital, Sydney, Australia
| | - Rémi Rabasa-Lhoret
- Montreal Clinical Research Institute (IRCM), Montréal, Québec, Canada; Department of Nutrition, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Division of Experimental Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada; Department of Medicine, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada; Cystic Fibrosis Clinic, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Québec, Canada.
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Auxological and Endocrinological Features in Children and Adolescents with Cystic Fibrosis. J Clin Med 2022; 11:jcm11144041. [PMID: 35887806 PMCID: PMC9323690 DOI: 10.3390/jcm11144041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 02/01/2023] Open
Abstract
Cystic fibrosis (CF) is a multisystem autosomal recessive disease caused by mutations that lead to deficient or dysfunctional CF transmembrane conductance regulator (CFTR) proteins. Patients typically present malnutrition resulting from the malabsorption of fundamental nutrients and recurring lung infections, with a progressive worsening of the respiratory function. For these reasons, the clinical management of CF requires a multidisciplinary team. From an endocrinological point of view, patients often present major complications, such as diabetes, bone disease, thyroid disorders, delayed growth and puberty, hypogonadism and infertility, which negatively affect their quality of life and, in some cases, significantly reduce life expectancy. These complications can arise as a direct result of CFTR dysfunction and/or as a consequence of a deterioration in the function of the organs affected. The objective of this review is to analyze all the possible endocrinological complications that can occur in patients with CF by evaluating the most recent papers in the literature.
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Moheet A, Moran A. New Concepts in the Pathogenesis of Cystic Fibrosis-Related Diabetes. J Clin Endocrinol Metab 2022; 107:1503-1509. [PMID: 35106591 DOI: 10.1210/clinem/dgac020] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Cystic fibrosis-related diabetes (CFRD) is the most common extrapulmonary complication of cystic fibrosis (CF). Approximately 40% of people with CF who are older than 20 years have CFRD. Presence of CFRD is associated with poor health outcomes in people with CF. OBJECTIVE This review summarizes current knowledge on pathophysiology of CFRD. METHODS A PubMed review of the literature was conducted, with search terms that included CFRD, cystic fibrosis, cystic fibrosis related diabetes, and cystic fibrosis transmembrane conductance regulator (CFTR). Additional sources were identified through manual searches of reference lists. Pathophysiology of CFRD: The pathophysiology underlying development of glucose tolerance abnormalities in CF is complex and not fully understood. β-cell loss and functional impairment of the remaining β-cell function results in progressive insulin insufficiency. Factors that may contribute to development of CFRD include local islet and systemic inflammation, alterations in the incretion hormone axis, varying degrees of insulin resistance and genetic factors related to type 2 diabetes. CONCLUSION The prevalence of CFRD is expected to further increase with improving life expectancy of people with CF. Further research is needed to better understand the mechanisms underlying the development of CFRD and the impact of diabetes on clinical outcomes in CF.
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Affiliation(s)
- Amir Moheet
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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The role of genetic modifiers, inflammation and CFTR in the pathogenesis of Cystic fibrosis related diabetes. J Clin Transl Endocrinol 2022; 27:100287. [PMID: 34976741 PMCID: PMC8688704 DOI: 10.1016/j.jcte.2021.100287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 11/20/2022] Open
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Raraigh KS, Aksit MA, Hetrick K, Pace RG, Ling H, O'Neal W, Blue E, Zhou YH, Bamshad MJ, Blackman SM, Gibson RL, Knowles MR, Cutting GR. Complete CFTR gene sequencing in 5,058 individuals with cystic fibrosis informs variant-specific treatment. J Cyst Fibros 2021; 21:463-470. [PMID: 34782259 DOI: 10.1016/j.jcf.2021.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cystic fibrosis (CF) is a recessive condition caused by variants in each CF transmembrane conductance regulator (CFTR) allele. Clinically affected individuals without two identified causal variants typically have no further interrogation of CFTR beyond examination of coding regions, but the development of variant-specific CFTR-targeted treatments necessitates complete understanding of CFTR genotype. METHODS Whole genome sequences were analyzed on 5,058 individuals with CF. We focused on the full CFTR gene sequence and identified disease-causing variants in three phases: screening for known and structural variants; discovery of novel loss-of-function variants; and investigation of remaining variants. RESULTS All variants identified in the first two phases and coding region variants found in the third phase were interpreted according to CFTR2 or ACMG criteria (n = 371; 16 [4.3%] previously unreported). Full gene sequencing enabled delineation of 18 structural variants (large insertions or deletions), of which two were novel. Additional CFTR variants of uncertain effect were found in 76 F508del homozygotes and in 21 individuals with other combinations of CF-causing variants. Both causative variants were identified in 98.1% (n = 4,960) of subjects, an increase of 2.3 percentage points from the 95.8% (n = 4,847) who had a registry- or chart-reported disease-causing CFTR genotype. Of the remaining 98 individuals, 78 carried one variant that has been associated with CF (CF-causing [n = 70] or resulting in varying clinical consequences n = 8]). CONCLUSIONS Complete CFTR gene sequencing in 5,058 individuals with CF identified at least one DNA variant in 99.6% of the cohort that is targetable by current molecular or emerging gene-based therapeutic technologies.
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Affiliation(s)
- Karen S Raraigh
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Melis A Aksit
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Kurt Hetrick
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Rhonda G Pace
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - Hua Ling
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
| | - Wanda O'Neal
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - Elizabeth Blue
- Department of Genome Sciences, University of Washington, Seattle, WA 98195, United States
| | - Yi-Hui Zhou
- Department of Biological Sciences, North Carolina State University, Raleigh, NC 27695, United States
| | - Michael J Bamshad
- Department of Genome Sciences, University of Washington, Seattle, WA 98195, United States; Department of Pediatrics, University of Washington, Seattle, WA 98195, United States; Brotman-Baty Institute, Seattle, WA 98195, United States
| | - Scott M Blackman
- Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University, Baltimore, MD 21287, United States
| | - Ronald L Gibson
- Department of Pediatrics, University of Washington, Seattle, WA 98195, United States
| | - Michael R Knowles
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - Garry R Cutting
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States.
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12
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Del Bosque-Plata L, Hernández-Cortés EP, Gragnoli C. The broad pathogenetic role of TCF7L2 in human diseases beyond type 2 diabetes. J Cell Physiol 2021; 237:301-312. [PMID: 34612510 PMCID: PMC9292842 DOI: 10.1002/jcp.30581] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 12/20/2022]
Abstract
The TCF7L2 protein is a key transcriptional effector of the Wnt/β‐catenin signaling pathway, regulating gene expression. It was initially identified in cancer research and embryologic developmental studies. Later, the TCF7L2 gene was linked to type 2 diabetes (T2D), implicating TCF7L2 and Wnt‐signaling in metabolic disorders and homeostasis. In fact, TCF7L2‐T2D variants confer the greatest relative risk for T2D, unquestionably predicting conversion to T2D in individuals with impaired glucose tolerance. We aim to describe the relevance of TCF7L2 in other human disorders. The TCF7L2‐single nucleotide polymorphisms (SNPs) and T2D‐risk association have been replicated in numerous follow‐up studies, and research has now been performed in several other diseases. In this article, we discuss common TCF7L2‐T2D variants within the framework of their association with human diseases. The TCF7L2 functional regions need to be further investigated because the molecular and cellular mechanisms through which TCF7L2 contributes to risk associations with different diseases are still not fully elucidated. In this review, we show the association of common TCF7L2‐T2D variants with many types of diseases. However, the role of rare genetic variations in the TCF7L2 gene in distinct diseases and ethnic groups has not been explored, and understanding their impact on specific phenotypes will be of clinical relevance. This offers an excellent opportunity to gain a clearer picture of the role that the TCF7L2 gene plays in the pathophysiology of human diseases. The potential pleiotropic role of TCF7L2 may underlie a possible pathway for comorbidity in human disorders.
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Affiliation(s)
- Laura Del Bosque-Plata
- Laboratorio de Nutrigenética y Nutrigenómica, Instituto Nacional de Medicina Genómica, Mexico City, Mexico
| | | | - Claudia Gragnoli
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolic Disease, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania.,Division of Endocrinology, Creighton University School of Medicine, Omaha, Nebraska, USA.,Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania, USA.,Molecular Biology Laboratory, Bios Biotech Multi-Diagnostic Health Center, Rome, Italy
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13
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Iafusco F, Maione G, Rosanio FM, Mozzillo E, Franzese A, Tinto N. Cystic Fibrosis-Related Diabetes (CFRD): Overview of Associated Genetic Factors. Diagnostics (Basel) 2021; 11:diagnostics11030572. [PMID: 33810109 PMCID: PMC8005125 DOI: 10.3390/diagnostics11030572] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 03/19/2021] [Indexed: 12/21/2022] Open
Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disease in the Caucasian population and is caused by mutations in the CF transmembrane conductance regulator (CFTR) gene that encodes for a chloride/bicarbonate channel expressed on the membrane of epithelial cells of the airways and of the intestine, as well as in cells with exocrine and endocrine functions. A common nonpulmonary complication of CF is cystic fibrosis-related diabetes (CFRD), a distinct form of diabetes due to insulin insufficiency or malfunction secondary to destruction/derangement of pancreatic betacells, as well as to other factors that affect their function. The prevalence of CFRD increases with age, and 40–50% of CF adults develop the disease. Several proposed hypotheses on how CFRD develops have emerged, including exocrine-driven fibrosis and destruction of the entire pancreas, as well as contrasting theories on the direct or indirect impact of CFTR mutation on islet function. Among contributors to the development of CFRD, in addition to CFTR genotype, there are other genetic factors related and not related to type 2 diabetes. This review presents an overview of the current understanding on genetic factors associated with glucose metabolism abnormalities in CF.
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Affiliation(s)
- Fernanda Iafusco
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, 80131 Naples, Italy; (F.I.); (G.M.)
- CEINGE Advanced Biotechnology, 80131 Naples, Italy
| | - Giovanna Maione
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, 80131 Naples, Italy; (F.I.); (G.M.)
- CEINGE Advanced Biotechnology, 80131 Naples, Italy
| | - Francesco Maria Rosanio
- Regional Center of Pediatric Diabetology, Department of Translational Medical Sciences, Section of Pediatrics, University of Naples “Federico II”, 80131 Naples, Italy; (F.M.R.); (E.M.); (A.F.)
| | - Enza Mozzillo
- Regional Center of Pediatric Diabetology, Department of Translational Medical Sciences, Section of Pediatrics, University of Naples “Federico II”, 80131 Naples, Italy; (F.M.R.); (E.M.); (A.F.)
| | - Adriana Franzese
- Regional Center of Pediatric Diabetology, Department of Translational Medical Sciences, Section of Pediatrics, University of Naples “Federico II”, 80131 Naples, Italy; (F.M.R.); (E.M.); (A.F.)
| | - Nadia Tinto
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, 80131 Naples, Italy; (F.I.); (G.M.)
- CEINGE Advanced Biotechnology, 80131 Naples, Italy
- Correspondence:
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14
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Abstract
Because CFTR gene studies now represent one of the most frequent genetic analyses routinely performed worldwide, the number of rare CFTR variants identified in various clinical situations, regularly increases. To provide appropriate diagnosis and prognosis to CF patients as well as appropriate genetic counseling to families, the clinical impact and the phenotypic spectrum of variants identified by diagnostic techniques need to be characterized. Three complementary locus specific databases, called CFTR1, CFTR2 and CFTR-France were developed to address these issues. Besides, the growing knowledge of the CF pathophysiology and the technical evolution in molecular biology allowed to identify candidate modifier genes, regulatory loci, epigenetic profiles and trans-regulators that could help to refine genotype-phenotype correlations at the individual level. These different factors may contribute to the large phenotypic variability between patients with CF, even when they carry identical CFTR variants, regarding lung function, meconium ileus susceptibility or the risk for developing CFTR-related diabetes and liver disease. Finally, the availability of new therapies that target the CFTR protein for numbers of CF patients led to the identification of 'good' and 'poor' responders, thus raising questions of pharmacogenetics factors that may influence treatment efficiency as a novel feature of the complexity of CF patients' management. © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.
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15
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Coriati A, Bouvet GF, Massé C, Ducruet T, Berthiaume Y. YKL-40 as a clinical biomarker in adult patients with CF: Implications of a CHI3L1 single nucleotide polymorphism in disease severity. J Cyst Fibros 2020; 20:e93-e99. [DOI: 10.1016/j.jcf.2020.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 11/09/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022]
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16
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Aksit MA, Pace RG, Vecchio-Pagán B, Ling H, Rommens JM, Boelle PY, Guillot L, Raraigh KS, Pugh E, Zhang P, Strug LJ, Drumm ML, Knowles MR, Cutting GR, Corvol H, Blackman SM. Genetic Modifiers of Cystic Fibrosis-Related Diabetes Have Extensive Overlap With Type 2 Diabetes and Related Traits. J Clin Endocrinol Metab 2020; 105:5599821. [PMID: 31697830 PMCID: PMC7236628 DOI: 10.1210/clinem/dgz102] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/02/2019] [Indexed: 02/08/2023]
Abstract
CONTEXT Individuals with cystic fibrosis (CF) develop a distinct form of diabetes characterized by β-cell dysfunction and islet amyloid accumulation similar to type 2 diabetes (T2D), but generally have normal insulin sensitivity. CF-related diabetes (CFRD) risk is determined by both CFTR, the gene responsible for CF, and other genetic variants. OBJECTIVE To identify genetic modifiers of CFRD and determine the genetic overlap with other types of diabetes. DESIGN AND PATIENTS A genome-wide association study was conducted for CFRD onset on 5740 individuals with CF. Weighted polygenic risk scores (PRSs) for type 1 diabetes (T1D), T2D, and diabetes endophenotypes were tested for association with CFRD. RESULTS Genome-wide significance was obtained for variants at a novel locus (PTMA) and 2 known CFRD genetic modifiers (TCF7L2 and SLC26A9). PTMA and SLC26A9 variants were CF-specific; TCF7L2 variants also associated with T2D. CFRD was strongly associated with PRSs for T2D, insulin secretion, postchallenge glucose concentration, and fasting plasma glucose, and less strongly with T1D PRSs. CFRD was inconsistently associated with PRSs for insulin sensitivity and was not associated with a PRS for islet autoimmunity. A CFRD PRS comprising variants selected from these PRSs (with a false discovery rate < 0.1) and the genome-wide significant variants was associated with CFRD in a replication population. CONCLUSIONS CFRD and T2D have more etiologic and mechanistic overlap than previously known, aligning along pathways involving β-cell function rather than insulin sensitivity. Two CFRD risk loci are unrelated to T2D and may affect multiple aspects of CF. An 18-variant PRS stratifies risk of CFRD in an independent population.
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Affiliation(s)
- Melis A Aksit
- McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rhonda G Pace
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Hua Ling
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland
| | - Johanna M Rommens
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Pierre-Yves Boelle
- Sorbonne Université, INSERM, Institut Pierre Louis d’Épidémiologie et de Santé Publique, iPLESP, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Loic Guillot
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Karen S Raraigh
- McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth Pugh
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland
| | - Peng Zhang
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland
| | - Lisa J Strug
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Michael R Knowles
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Garry R Cutting
- McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harriet Corvol
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Scott M Blackman
- McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Correspondence and Reprint Requests: Scott M. Blackman, McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205. E-mail:
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17
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Paranjapye A, Ruffin M, Harris A, Corvol H. Genetic variation in CFTR and modifier loci may modulate cystic fibrosis disease severity. J Cyst Fibros 2020; 19 Suppl 1:S10-S14. [PMID: 31734115 PMCID: PMC7036019 DOI: 10.1016/j.jcf.2019.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/04/2019] [Accepted: 11/07/2019] [Indexed: 12/11/2022]
Abstract
In patients with cystic fibrosis (CF), genetic variants within and outside the CFTR locus contribute to the variability of the disease severity. CFTR transcription is tightly regulated by cis-regulatory elements (CREs) that control the three-dimensional structure of the locus, chromatin accessibility and transcription factor recruitment. Variants within these CREs may contribute to the pathophysiology and to the phenotypic heterogeneity by altering CFTR transcript abundance. In addition to the CREs, variants outside the CFTR locus, namely "modifiers genes", may also be associated with the clinical variability. This review addresses variants at the CFTR locus itself and CFTR CREs, together with the outcomes of the latest modifier gene studies with respect to the different CF phenotypes.
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Affiliation(s)
- Alekh Paranjapye
- Department of Genetics and Genome Sciences, Case Western Reserve University Medical School, 10900 Euclid Avenue, Cleveland, OH, USA
| | - Manon Ruffin
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Ann Harris
- Department of Genetics and Genome Sciences, Case Western Reserve University Medical School, 10900 Euclid Avenue, Cleveland, OH, USA.
| | - Harriet Corvol
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, Paris, France; AP-HP, Hôpital Trousseau, Service de Pneumologie Pédiatrique, Paris, France.
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18
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19
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Sharma N, Cutting GR. The genetics and genomics of cystic fibrosis. J Cyst Fibros 2019; 19 Suppl 1:S5-S9. [PMID: 31879237 DOI: 10.1016/j.jcf.2019.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 02/07/2023]
Abstract
Genetics is the branch of biology concerned with study of individual genes and how they work whereas genomics is involved with the analysis of all genes and their interactions. Both of these approaches have been applied extensively to CF. Identification of the CFTR gene initiated the dissection of CF genetics at the molecular level. Subsequently, thousands of variants were found in the gene and the functional consequences of a subset have been studied in detail. The completion of the human genome ushered in a new phase of study where the role of genes beyond CFTR could be evaluated for their contribution to the severity of CF. This will be a brief overview of the contribution of these complementary methods to our understanding of CF pathogenesis.
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Affiliation(s)
- N Sharma
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - G R Cutting
- Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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20
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Granados A, Chan CL, Ode KL, Moheet A, Moran A, Holl R. Cystic fibrosis related diabetes: Pathophysiology, screening and diagnosis. J Cyst Fibros 2019; 18 Suppl 2:S3-S9. [DOI: 10.1016/j.jcf.2019.08.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
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21
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Grant SFA. The TCF7L2 Locus: A Genetic Window Into the Pathogenesis of Type 1 and Type 2 Diabetes. Diabetes Care 2019; 42:1624-1629. [PMID: 31409726 PMCID: PMC6702598 DOI: 10.2337/dci19-0001] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/12/2019] [Indexed: 02/03/2023]
Abstract
Over the past ∼15 years there has been great progress in our understanding of the genetics of both type 1 diabetes and type 2 diabetes. This has been driven principally by genome-wide association studies (GWAS) in increasingly larger sample sizes, where many distinct loci have now been reported for both traits. One of the loci that dominates these studies is the TCF7L2 locus for type 2 diabetes. This genetic signal has been leveraged to explore multiple aspects of disease risk, including developments in genetic risk scores, genetic commonalities with cancer, and for gaining insights into diabetes-related molecular pathways. Furthermore, the TCF7L2 locus has aided in providing insights into the genetics of both latent autoimmune diabetes in adults and various presentations of type 1 diabetes. This review outlines the knowledge gained to date and highlights how work with this locus leads the way in guiding how many other genetic loci could be similarly used to gain insights into the pathogenesis of diabetes.
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Affiliation(s)
- Struan F A Grant
- Divisions of Human Genetics and Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Spatial and Functional Genomics, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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22
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Redondo MJ, Evans-Molina C, Steck AK, Atkinson MA, Sosenko J. The Influence of Type 2 Diabetes-Associated Factors on Type 1 Diabetes. Diabetes Care 2019; 42:1357-1364. [PMID: 31167894 PMCID: PMC6647039 DOI: 10.2337/dc19-0102] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/27/2019] [Indexed: 02/03/2023]
Abstract
Current efforts to prevent progression from islet autoimmunity to type 1 diabetes largely focus on immunomodulatory approaches. However, emerging data suggest that the development of diabetes in islet autoantibody-positive individuals may also involve factors such as obesity and genetic variants associated with type 2 diabetes, and the influence of these factors increases with age at diagnosis. Although these factors have been linked with metabolic outcomes, particularly through their impact on β-cell function and insulin sensitivity, growing evidence suggests that they might also interact with the immune system to amplify the autoimmune response. The presence of factors shared by both forms of diabetes contributes to disease heterogeneity and thus has important implications. Characteristics that are typically considered to be nonimmune should be incorporated into predictive algorithms that seek to identify at-risk individuals and into the designs of trials for disease prevention. The heterogeneity of diabetes also poses a challenge in diagnostic classification. Finally, after clinically diagnosing type 1 diabetes, addressing nonimmune elements may help to prevent further deterioration of β-cell function and thus improve clinical outcomes. This Perspectives in Care article highlights the role of type 2 diabetes-associated genetic factors (e.g., gene variants at transcription factor 7-like 2 [TCF7L2]) and obesity (via insulin resistance, inflammation, β-cell stress, or all three) in the pathogenesis of type 1 diabetes and their impacts on age at diagnosis. Recognizing that type 1 diabetes might result from the sum of effects from islet autoimmunity and type 2 diabetes-associated factors, their interactions, or both affects disease prediction, prevention, diagnosis, and treatment.
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Affiliation(s)
- Maria J Redondo
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN.,Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN.,Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Mark A Atkinson
- Departments of Pathology and Pediatrics, University of Florida Diabetes Institute, Gainesville, FL
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Perrem L, Stanojevic S, Solomon M, Carpenter S, Ratjen F. Incidence and risk factors of paediatric cystic fibrosis-related diabetes. J Cyst Fibros 2019; 18:874-878. [PMID: 31072797 DOI: 10.1016/j.jcf.2019.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 04/19/2019] [Accepted: 04/19/2019] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Cystic fibrosis-related diabetes (CFRD) is a common complication of cystic fibrosis (CF) directly linked to increased morbidity and mortality. Both the incidence of type I and type II diabetes has been shown to increase in the general population. In this study, we investigated the incidence and risk factors of CFRD in a paediatric CF population. METHODS Prospectively collected data from the Canadian CF Registry (CCFR) from 2000 to 2016 for patients ages 10 to 18 years was used to determine the incidence of CFRD. Risk factors for CFRD in the Canadian population were investigated using a nested case-control design. Conditional logistic regression analysis with a 4:1 control: case matching was used. RESULTS From 2000 to 2016, 2326 patients with CF aged between 10 through 18 years were included in the CCFR, during this time the overall incidence rate of CFRD was 2.1 cases per 100 patient-years (95% confidence interval 1.8 to 2.3). Incidence rates were stable in the Canadian cohort over three consecutive time periods 2000-2005, 2006-2010; 2011-2016. Worse lung function, female gender, history of allergic bronchopulmonary aspergillosis, Gastrostomy tube insertion and liver disease were statistically significant risk factors for CFRD. CONCLUSION The incidence of CFRD in the Canadian paediatric population has been stable over time, in contrast to the rising rates of Type 1 and Type 2 diabetes in the general paediatric population. The risk factor for CFRD in this contemporary population were consistent with previous studies.
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Affiliation(s)
- Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sanja Stanojevic
- Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Melinda Solomon
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Susan Carpenter
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Felix Ratjen
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada; Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, University of Toronto, Toronto, ON, Canada.
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Abstract
PURPOSE OF REVIEW To compile data from the past 10 years regarding the role of modifying genes in cystic fibrosis (CF). RECENT FINDINGS CF is a model disease for understanding of the action of modifying genes. Although it is a monogenic (CFTR) autosomal recessive disease, CF presents with wide phenotypic variability. In CF, variability occurs with different intensity among patients by each organ, being organ-specific, resulting from the mutual interaction of environmental and genetic factors, including CFTR mutations and various other genes, most of which are associated with inflammatory processes. In individuals, using precision medicine, gene modification studies have revealed individualized responses to drugs depending on particular CFTR mutations and modifying genes, most of which are alternative ion channels. SUMMARY Studies of modifying genes in CF allow: understanding of clinical variability among patients with the same CFTR genotype; evaluation of precision medicine; understanding of environmental and genetic effects at the organ level; understanding the involvement of genetic variants in inflammatory responses; improvements in genetic counseling; understanding the involvement of genetic variants in inflammatory responses in lung diseases, such as asthma; and understanding the individuality of the person with the disease.
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25
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Wynne K, Devereaux B, Dornhorst A. Diabetes of the exocrine pancreas. J Gastroenterol Hepatol 2019; 34:346-354. [PMID: 30151918 DOI: 10.1111/jgh.14451] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 07/31/2018] [Accepted: 08/19/2018] [Indexed: 12/11/2022]
Abstract
Diabetes of the exocrine pancreas (DEP) is a form of diabetes that occurs due to pancreatic disease. It is far more common than has been previously considered, with a recent study showing 1.8% of adults with new-onset diabetes should have been classified as DEP. The majority is misdiagnosed as type 2 diabetes mellitus (T2DM). Patients with DEP exhibit varying degrees of exocrine and endocrine dysfunction. Damage to the islet of Langerhans effects the secretion of hormones from the β, α, and pancreatic polypeptide cells; the combination of low insulin, glucagon, and pancreatic polypeptide contributes to rapid fluctuations in glucose levels. This form of "brittle diabetes" may result in the poorer glycemic control observed in patients with DEP, when compared with those with T2DM. Diabetes of the exocrine pancreas has a different natural history to other forms of diabetes; patients are more likely to require early insulin initiation compared with those with T2DM. Therefore, individuals with DEP should be advised about the symptoms of decompensated hyperglycemia, although they are less likely to develop ketoacidosis. Clinicians should screen for DEP in patients with acute or chronic pancreatitis, following pancreatic resection, or with co-existing cystic fibrosis or hemochromatosis. Incident diabetes may herald the onset of pancreatic ductal carcinoma in a small subset of patients. Once identified, patients with DEP can benefit from specific lifestyle advice, pancreatic enzyme replacement therapy, metformin treatment, appropriate insulin dosing, and monitoring. Further research is needed to establish the ideal treatment regimens to provide optimal clinical outcomes for this unique form of diabetes.
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Affiliation(s)
- Katie Wynne
- Department of Diabetes and Endocrinology, John Hunter Hospital, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Benedict Devereaux
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - Anne Dornhorst
- Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK.,Imperial College London, London, UK
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Smith DJ, Klein K, Hartel G, Wainwright CE, Bell SC, Anderson GJ, Reid DW. Mutations in the HFE gene can be associated with increased lung disease severity in cystic fibrosis. Gene 2019; 683:12-17. [DOI: 10.1016/j.gene.2018.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 09/06/2018] [Accepted: 10/01/2018] [Indexed: 02/04/2023]
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27
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Pollard BS, Pollard HB. Induced pluripotent stem cells for treating cystic fibrosis: State of the science. Pediatr Pulmonol 2018; 53:S12-S29. [PMID: 30062693 DOI: 10.1002/ppul.24118] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 05/31/2018] [Indexed: 12/20/2022]
Abstract
Induced pluripotent stem cells (iPSCs) are a recently developed technology in which fully differentiated cells such as fibroblasts from individual CF patients can be repaired with [wildtype] CFTR, and reprogrammed to differentiate into fully differentiated cells characteristic of the proximal and distal airways. Here, we review properties of different epithelial cells in the airway, and the in vitro genetic roadmap which iPSCs follow as they are step-wise differentiated into either basal stem cells, for the proximal airway, or into Type II Alveolar cells for the distal airways. The central theme is that iPSC-derived basal stem cells, are penultimately dependent on NOTCH signaling for differentiation into club cells, goblet cells, ciliated cells, and neuroendocrine cells. Furthermore, given the proper matrix, these cellular progenies are also able to self-assemble into a fully functional pseudostratified squamous proximal airway epithelium. By contrast, club cells are reserve stem cells which are able to either differentiate into goblet or ciliated cells, but also to de-differentiate into basal stem cells. Variant club cells, located at the transition between airway and alveoli, may also be responsible for differentiation into Type II Alveolar cells, which then differentiate into Type I Alveolar cells for gas exchange in the distal airway. Using gene editing, the mutant CFTR gene in iPSCs from CF patients can be repaired, and fully functional epithelial cells can thus be generated through directed differentiation. However, there is a limitation in that the lung has other CFTR-dependent cells besides epithelial cells. Another limitation is that there are CFTR-dependent cells in other organs which would continue to contribute to CF disease. Furthermore, there are also bystander or modifier genes which affect disease outcome, not only in the lung, but specifically in other CF-affected organs. Finally, we discuss future personalized applications of the iPSC technology, many of which have already survived the "proof-of-principle" test. These include (i) patient-derived iPSCs used as a "lung-on-a-chip" tool for personalized drug discovery; (ii) replacement of mutant lung cells by wildtype lung cells in the living lung; and (iii) development of bio-artificial lungs. It is hoped that this review will give the reader a roadmap through the most complicated of the obstacles, and foster a guardedly optimistic view of how some of the remaining obstacles might one day be overcome.
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Affiliation(s)
| | - Harvey B Pollard
- Department of Cell Biology and Genetics, Uniformed Services University School of Medicine-America's Medical School, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Moran A, Pillay K, Becker D, Granados A, Hameed S, Acerini CL. ISPAD Clinical Practice Consensus Guidelines 2018: Management of cystic fibrosis-related diabetes in children and adolescents. Pediatr Diabetes 2018; 19 Suppl 27:64-74. [PMID: 30094886 DOI: 10.1111/pedi.12732] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 07/13/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | | | - Dorothy Becker
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrea Granados
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Shihab Hameed
- Department of Endocrinology, Sydney Children's Hospital, Randwick, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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29
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O'Neal WK, Knowles MR. Cystic Fibrosis Disease Modifiers: Complex Genetics Defines the Phenotypic Diversity in a Monogenic Disease. Annu Rev Genomics Hum Genet 2018; 19:201-222. [DOI: 10.1146/annurev-genom-083117-021329] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
In many respects, genetic studies in cystic fibrosis (CF) serve as a paradigm for a human Mendelian genetic success story. From recognition of the condition as a heritable pathological entity to implementation of personalized treatments based on genetic findings, this multistep pathway of progress has focused on the genetic underpinnings of CF clinical disease. Along this path was the recognition that not all CFTR gene mutations produce the same disease and the recognition of the complex, multifactorial nature of CF genotype–phenotype relationships. The non- CFTR genetic components (gene modifiers) that contribute to variation in phenotype are the focus of this review. A multifaceted approach involving candidate gene studies, genome-wide association studies, and gene expression studies has revealed significant gene modifiers for multiple CF phenotypes. The bold challenges for the future are to integrate the findings into our understanding of CF pathogenesis and to use the knowledge to develop novel therapies.
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Affiliation(s)
- Wanda K. O'Neal
- Cystic Fibrosis/Pulmonary Research and Treatment Center, Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA;,
| | - Michael R. Knowles
- Cystic Fibrosis/Pulmonary Research and Treatment Center, Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA;,
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30
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Hull RL, Gibson RL, McNamara S, Deutsch GH, Fligner CL, Frevert CW, Ramsey BW, Sanda S. Islet Interleukin-1β Immunoreactivity Is an Early Feature of Cystic Fibrosis That May Contribute to β-Cell Failure. Diabetes Care 2018; 41:823-830. [PMID: 29437698 PMCID: PMC5860832 DOI: 10.2337/dc17-1387] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 01/06/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Cystic fibrosis-related diabetes (CFRD) is a common complication of cystic fibrosis (CF), increasing patient morbidity and mortality. Poor understanding of CFRD pathogenesis limits the development of targeted therapies to treat and/or prevent the disease. The aim of this study was to evaluate islet pathology, specifically, inflammation, amyloid deposition, and endocrine cell composition in subjects with CF with diabetes and with CF without diabetes. RESEARCH DESIGN AND METHODS A retrospective analysis of archived pancreas tissue collected at autopsy was conducted using pancreas tissue from subjects with CF and diabetes (CFRD) (n = 18) and CF without diabetes (CF-no DM) (n = 17). Two cohorts of control non-CF subjects were identified, each matched to CFRD and CF-no DM subjects for age, sex, and BMI (non-CF older, n = 20, and non-CF younger, n = 20), respectively. Immunohistochemistry was performed to assess interleukin-1β (IL-1β) and islet hormone (insulin, glucagon, somatostatin, and pancreatic polypeptide) immunoreactivity; histochemistry was performed to quantify amyloid deposition. RESULTS Islet IL-1β immunoreactivity was substantially increased in both CFRD and CF-no DM subjects compared with non-CF subjects and was common in young subjects with CF (≤10 years of age). In contrast, islet amyloid deposition was increased only in CFRD subjects. We also observe abnormal islet hormone immunoreactivity, characterized by increased glucagon immunoreactivity, in CF-no DM and CFRD subjects compared with non-CF subjects. CONCLUSIONS These findings reveal novel molecular pathways and therapeutic targets underlying islet pathology in CF subjects and may be important in developing new approaches to treat CFRD.
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Affiliation(s)
- Rebecca L Hull
- Department of Medicine, University of Washington, Seattle, WA
| | - Ronald L Gibson
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Sharon McNamara
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Gail H Deutsch
- Department of Pathology, University of Washington, Seattle, WA
| | | | - Charles W Frevert
- Department of Medicine, University of Washington, Seattle, WA.,Department of Comparative Medicine, University of Washington, Seattle, WA
| | - Bonnie W Ramsey
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Srinath Sanda
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA .,Diabetes Center, University of California, San Francisco, San Francisco, CA
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Affiliation(s)
- R David Leslie
- Department of Immunobiology, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, U.K.
| | - Struan F A Grant
- Divisions of Human Genetics and Endocrinology, Children's Hospital of Philadelphia, Philadelphia, PA .,Departments of Pediatrics and Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Institute for Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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32
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Paranjape SM, Mogayzel PJ. Cystic fibrosis in the era of precision medicine. Paediatr Respir Rev 2018; 25:64-72. [PMID: 28372929 DOI: 10.1016/j.prrv.2017.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/03/2017] [Indexed: 02/06/2023]
Abstract
The treatment of people with cystic fibrosis (CF) has been transformed by the availability of drugs that target the basic chloride defect in the disease. The use of drugs that target specific molecular defects embodies the goals of precision medicine, which incorporate preventive and therapeutic strategies and takes into account differences among individuals. However, the entirety of CF care, from diagnosis to understanding the clinical phenotype and developing a therapeutic strategy, depends on taking into account individual characteristics to achieve optimal outcomes. Future therapies are likely to be even more individualized ushering in a new era of precision medicine.
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Affiliation(s)
- Shruti M Paranjape
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
| | - Peter J Mogayzel
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
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33
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Moheet A, Moran A. CF-related diabetes: Containing the metabolic miscreant of cystic fibrosis. Pediatr Pulmonol 2017; 52:S37-S43. [PMID: 28714601 DOI: 10.1002/ppul.23762] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/15/2017] [Indexed: 01/20/2023]
Abstract
Cystic fibrosis-related diabetes (CFRD) is associated with both an increase in morbidity and mortality in people with cystic fibrosis (CF). With increased screening and improved life expectancy of people with CF, the prevalence of CFRD is expected to rise further. The underlying pathophysiological mechanisms causing glucose intolerance and diabetes in patients with CF are not well understood but both functional and structural abnormalities in islet cells are likely to have key roles. Insulin therapy improves health outcomes in patients with CF. Future research is needed to better understand the mechanisms underlying the development of CFRD and to develop new screening and treatment strategies to minimize the detrimental impact of CFRD on health outcomes in people with CF.
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Affiliation(s)
- Amir Moheet
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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34
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Yi Y, Norris AW, Wang K, Sun X, Uc A, Moran A, Engelhardt JF, Ode KL. Abnormal Glucose Tolerance in Infants and Young Children with Cystic Fibrosis. Am J Respir Crit Care Med 2017; 194:974-980. [PMID: 27447840 DOI: 10.1164/rccm.201512-2518oc] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE In cystic fibrosis, abnormal glucose tolerance is associated with decreased lung function and worsened outcomes. Translational evidence indicates that abnormal glucose tolerance may begin in early life. OBJECTIVES To determine whether very young children with cystic fibrosis have increased abnormal glucose tolerance prevalence compared with control subjects. The secondary objective was to compare area under the curve for glucose and insulin in children with cystic fibrosis with control subjects. METHODS This is a prospective multicenter study in children ages 3 months to 5 years with and without cystic fibrosis. MEASUREMENTS AND MAIN RESULTS Oral glucose tolerance testing with glucose, insulin, and C-peptide was sampled at 0, 10, 30, 60, 90, and 120 minutes. Twenty-three children with cystic fibrosis and nine control subjects had complete data. All control subjects had normal glucose tolerance. Nine of 23 subjects with cystic fibrosis had abnormal glucose tolerance (39%; P = 0.03). Of those, two met criteria for cystic fibrosis-related diabetes, two indeterminate glycemia, and six impaired glucose tolerance. Children with cystic fibrosis failed to exhibit the normal increase in area under the curve insulin with age observed in control subjects (P < 0.01), despite increased area under the curve glucose (P = 0.02). CONCLUSIONS Abnormal glucose tolerance is notably prevalent among young children with cystic fibrosis. Children with cystic fibrosis lack the normal increase in insulin secretion that occurs in early childhood despite increased glucose. These findings demonstrate that glycemic abnormalities begin very early in cystic fibrosis, possibly because of insufficient insulin secretion.
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Affiliation(s)
- Yaling Yi
- 1 Department of Anatomy and Cell Biology
| | - Andrew W Norris
- 2 Department of Pediatrics.,3 Fraternal Order of Eagles Diabetes Research Center, and
| | - Kai Wang
- 4 Department of Biostatistics, College of Public Health, University of Iowa, Iowa City, Iowa; and
| | | | | | - Antoinette Moran
- 5 Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - John F Engelhardt
- 1 Department of Anatomy and Cell Biology.,3 Fraternal Order of Eagles Diabetes Research Center, and
| | - Katie Larson Ode
- 2 Department of Pediatrics.,3 Fraternal Order of Eagles Diabetes Research Center, and
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35
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Akhtar Y, Blackman SM. Hyperglycemia in Young Children with Cystic Fibrosis. Am J Respir Crit Care Med 2016; 194:924-925. [DOI: 10.1164/rccm.201608-1579ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Yasmin Akhtar
- Division of Pediatric EndocrinologyJohns Hopkins University School of MedicineBaltimore, Maryland
| | - Scott M. Blackman
- Division of Pediatric EndocrinologyJohns Hopkins University School of MedicineBaltimore, Maryland
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36
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Abstract
Cystic fibrosis is frequently complicated by endocrine disorders. Diabetes can be expected to affect most with CF and pancreatic insufficiency and varies widely in age of onset, but early identification and treatment improve morbidity and mortality. Short stature can be exacerbated by relative delay of puberty and by use of inhaled corticosteroids. Bone disease in CF causes fragility fractures and should be assessed by monitoring bone mineral density and optimizing vitamin D status. Detecting and managing endocrine complications in CF can reduce morbidity and mortality in CF. These complications can be expected to become more common as the CF population ages.
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Affiliation(s)
- Scott M. Blackman
- Division of Pediatric Endocrinology, Department of Pediatrics, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, MD
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine and the Atlanta VA Medical Center, Atlanta, GA
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37
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Prentice B, Hameed S, Verge CF, Ooi CY, Jaffe A, Widger J. Diagnosing cystic fibrosis-related diabetes: current methods and challenges. Expert Rev Respir Med 2016; 10:799-811. [DOI: 10.1080/17476348.2016.1190646] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Bernadette Prentice
- Department of Respiratory Medicine, Sydney Children’s Hospital, Randwick, Australia
- School of Women’s and Children’s Health, The University of New South Wales, Randwick, Australia
| | - Shihab Hameed
- School of Women’s and Children’s Health, The University of New South Wales, Randwick, Australia
- Department of Endocrinology, Sydney Children’s Hospital, Randwick, Australia
| | - Charles F. Verge
- School of Women’s and Children’s Health, The University of New South Wales, Randwick, Australia
- Department of Endocrinology, Sydney Children’s Hospital, Randwick, Australia
| | - Chee Y. Ooi
- School of Women’s and Children’s Health, The University of New South Wales, Randwick, Australia
- Department of Gastroenterology, Sydney Children’s Hospital, Randwick, Australia
| | - Adam Jaffe
- Department of Respiratory Medicine, Sydney Children’s Hospital, Randwick, Australia
- School of Women’s and Children’s Health, The University of New South Wales, Randwick, Australia
| | - John Widger
- Department of Respiratory Medicine, Sydney Children’s Hospital, Randwick, Australia
- School of Women’s and Children’s Health, The University of New South Wales, Randwick, Australia
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38
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Jin T. Current Understanding on Role of the Wnt Signaling Pathway Effector TCF7L2 in Glucose Homeostasis. Endocr Rev 2016; 37:254-77. [PMID: 27159876 DOI: 10.1210/er.2015-1146] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The role of the Wnt signaling pathway in metabolic homeostasis has drawn our intensive attention, especially after the genome-wide association study discovery that certain polymorphisms of its key effector TCF7L2 are strongly associated with the susceptibility to type 2 diabetes. For a decade, great efforts have been made in determining the function of TCF7L2 in various metabolic organs, which have generated both considerable achievements and disputes. In this review, I will briefly introduce the canonical Wnt signaling pathway, focusing on its effector β-catenin/TCF, including emphasizing the bidirectional feature of TCFs and β-catenin post-translational modifications. I will then summarize the observations on the association between TCF7L2 polymorphisms and type 2 diabetes risk. The main content, however, is on the intensive functional exploration of the metabolic role of TCF7L2, including the disputes generated on determining its role in the pancreas and liver with various transgenic mouse lines. Finally, I will discuss those achievements and disputes and present my future perspectives.
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Affiliation(s)
- Tianru Jin
- Division of Advanced Diagnostics, Toronto General Research Institute, University Health Network, Toronto, ON M5G 2C4, Canada
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39
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Fontés G, Ghislain J, Benterki I, Zarrouki B, Trudel D, Berthiaume Y, Poitout V. The ΔF508 Mutation in the Cystic Fibrosis Transmembrane Conductance Regulator Is Associated With Progressive Insulin Resistance and Decreased Functional β-Cell Mass in Mice. Diabetes 2015; 64:4112-22. [PMID: 26283735 PMCID: PMC4876763 DOI: 10.2337/db14-0810] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 08/10/2015] [Indexed: 01/20/2023]
Abstract
Cystic fibrosis (CF) is the result of mutations in the cystic fibrosis transmembrane conductance regulator (CFTR). CF-related diabetes affects 50% of adult CF patients. How CFTR deficiency predisposes to diabetes is unknown. Herein, we examined the impact of the most frequent cftr mutation in humans, deletion of phenylalanine at position 508 (ΔF508), on glucose homeostasis in mice. We compared ΔF508 mutant mice with wild-type (WT) littermates. Twelve-week-old male ΔF508 mutants had lower body weight, improved oral glucose tolerance, and a trend toward higher insulin tolerance. Glucose-induced insulin secretion was slightly diminished in ΔF508 mutant islets, due to reduced insulin content, but ΔF508 mutant islets were not more sensitive to proinflammatory cytokines than WT islets. Hyperglycemic clamps confirmed an increase in insulin sensitivity with normal β-cell function in 12- and 18-week-old ΔF508 mutants. In contrast, 24-week-old ΔF508 mutants exhibited insulin resistance and reduced β-cell function. β-Cell mass was unaffected at 11 weeks of age but was significantly lower in ΔF508 mutants versus controls at 24 weeks. This was not associated with gross pancreatic pathology. We conclude that the ΔF508 CFTR mutation does not lead to an intrinsic β-cell secretory defect but is associated with insulin resistance and a β-cell mass deficit in aging mutants.
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Affiliation(s)
- Ghislaine Fontés
- Montreal Diabetes Research Center, University of Montreal, Quebec, Canada University of Montreal Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada
| | - Julien Ghislain
- Montreal Diabetes Research Center, University of Montreal, Quebec, Canada University of Montreal Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada
| | - Isma Benterki
- Montreal Diabetes Research Center, University of Montreal, Quebec, Canada University of Montreal Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada Department of Biochemistry and Molecular Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Bader Zarrouki
- Montreal Diabetes Research Center, University of Montreal, Quebec, Canada University of Montreal Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada
| | - Dominique Trudel
- University of Montreal Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada Department of Pathology and Cell Biology, University of Montreal, Montreal, Quebec, Canada
| | - Yves Berthiaume
- University of Montreal Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Vincent Poitout
- Montreal Diabetes Research Center, University of Montreal, Quebec, Canada University of Montreal Hospital Research Centre, University of Montreal, Montreal, Quebec, Canada Department of Biochemistry and Molecular Medicine, University of Montreal, Montreal, Quebec, Canada Department of Medicine, University of Montreal, Montreal, Quebec, Canada
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Abstract
PURPOSE OF REVIEW This review will outline the screening, diagnosis and management of cystic fibrosis related diabetes (CFRD). It will also discuss advances in the detection of early glucose abnormalities, their clinical significance and the emerging role for early insulin therapy. RECENT FINDINGS Before the onset of diabetes (as currently defined), patients with cystic fibrosis (CF) display glucose abnormalities, detectable either by 30-minutely sampled oral glucose tolerance testing (OGTT), or by continuous ambulatory interstitial glucose monitoring (CGM). These early glucose abnormalities are associated with the presence of glucose in airway fluid, potentially promoting the growth of airway pathogens and contributing to the progression of respiratory disease. Progressive insulin deficiency underlies these glucose abnormalities, and insulin deficiency also causes catabolism. Pilot studies of once-daily insulin therapy in the early stages of insulin deficiency show improved lung function and weight gain (important predictors of survival in CF). SUMMARY Early stages of insulin deficiency may be contributing to catabolism and deteriorating lung function in CF. It is plausible that early insulin therapy may prevent this deterioration, a view supported by pilot studies. Randomized controlled trials of early insulin therapy will now determine whether insulin therapy should be commenced earlier than current practice in CF.
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Corvol H, Taytard J, Tabary O, Le Rouzic P, Guillot L, Clement A. Les enjeux de la médecine personnalisée appliquée à la mucoviscidose. Arch Pediatr 2015; 22:778-86. [DOI: 10.1016/j.arcped.2015.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/04/2015] [Accepted: 04/24/2015] [Indexed: 11/26/2022]
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Siwamogsatham O, Alvarez J, Tangpricha V. Diagnosis and treatment of endocrine comorbidities in patients with cystic fibrosis. Curr Opin Endocrinol Diabetes Obes 2014; 21:422-9. [PMID: 25105995 PMCID: PMC4326081 DOI: 10.1097/med.0000000000000096] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE OF REVIEW The aim of this review is to provide an update on various relevant endocrine aspects of care in adolescents and adults with cystic fibrosis. RECENT FINDINGS As life expectancy in cystic fibrosis has continuously improved, endocrine complications have become more apparent. The common endocrine complications include cystic fibrosis related diabetes, cystic fibrosis related bone disease, vitamin D deficiency and poor growth and pubertal development. Thyroid and adrenal disorders have also been reported, although the prevalence appears to be less common. SUMMARY Endocrine diseases are an increasingly recognized complication that has a significant impact on the overall health of individuals with cystic fibrosis. This review summarizes the updated screening and management of endocrine diseases in the cystic fibrosis population.
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Affiliation(s)
- Oranan Siwamogsatham
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Samitivej Srinakarin Hospital, Bangkok Hospital Group, Bangkok, Thailand,
| | - Jessica Alvarez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA,
| | - Vin Tangpricha
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
- Emory Adult Cystic Fibrosis Program, Emory Healthcare, Atlanta, GA
- Section of Endocrinology, Atlanta VA Medical Center, Decatur, GA, 101 Woodruff Circle NE- WMRB1301, Atlanta, GA 30322, Phone (404) 727-7254, Fax (404) 592-6257,
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43
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Rayas MS, Willey-Courand DB, Lynch JL, Guajardo JR. Improved screening for cystic fibrosis-related diabetes by an integrated care team using an algorithm. Pediatr Pulmonol 2014; 49:971-7. [PMID: 24436252 DOI: 10.1002/ppul.22988] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 12/07/2013] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To determine whether implementation of a standardized, clinic-based algorithm improves compliance with cystic fibrosis-related diabetes (CFRD) screening guidelines. STUDY DESIGN A CFRD screening algorithm was developed as part of a quality improvement initiative through collaboration between the pediatric pulmonary and endocrine divisions and implemented prospectively to children aged 8-17 years in our CF center for a 6-month period. The primary outcome measure was the percentage rate of CF patients who were appropriately screened with an oral glucose tolerance test (OGTT) during the quality improvement period as compared to the year prior. RESULTS Ninety-seven percent (37/38) of OGTTs were appropriately ordered by providers, and 89% (34/38) of patients obtained the OGTT at the completion of the quality improvement period. Compared with the percentage of eligible patients completing the OGTT the year prior, the use of the algorithm significantly improved screening (P = 0.03). Data collected 1-year post-algorithm implementation revealed 97% (33/34) of OGTTs were ordered and 79% (27/34) of OGTTs were completed. The use of the algorithm 1-year post-implementation did not reveal a significant improvement in screening when compared to the reference year and implementation period (P = 0.08). CONCLUSIONS Implementation of a clinical algorithm resulted in a statistically significant improvement in screening during the quality improvement period, but this improvement was not sustained the following year despite continued physician compliance with ordering the OGTT. Barriers to patient compliance need to be explored.
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Affiliation(s)
- Maria Socorro Rayas
- Division of Pediatric Endocrinology and Diabetes, University of Texas Health Science Center in San Antonio, San Antonio, Texas
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44
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Moran A, Pillay K, Becker DJ, Acerini CL. ISPAD Clinical Practice Consensus Guidelines 2014. Management of cystic fibrosis-related diabetes in children and adolescents. Pediatr Diabetes 2014; 15 Suppl 20:65-76. [PMID: 25182308 DOI: 10.1111/pedi.12178] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 06/11/2014] [Indexed: 12/17/2022] Open
Affiliation(s)
- Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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45
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Abstract
Improved life expectancy in cystic fibrosis (CF) has led to an expanding population of adults with CF, now representing almost 50 % of the total CF population. This creates new challenges from long-term complications such as diabetes mellitus (DM), a condition that is present in 40 %-50 % of adults with CF. Cystic fibrosis-related diabetes (CFRD) results from a primary defect of insulin deficiency and although sharing features with type 1 (DM1) and type 2 diabetes (DM2), it is a clinically distinct condition. Progression to diabetes is associated with poorer CF clinical outcomes and increased mortality. CFRD is not associated with an increased risk of cardiovascular disease and the prevalence of microvascular complications is lower than DM1 or DM2. Rather, the primary goal of insulin therapy is the preservation of lung function and optimization of nutritional status. There is increasing evidence that appropriate screening and early intervention with insulin can reverse weight loss and improve pulmonary function. This approach may include targeting postprandial hyperglycemia not detected by standard diagnostic tests such as the oral glucose tolerance test. Further clinical research is required to guide when and how much to intervene in patients who are already dealing with the burden of one chronic illness.
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Affiliation(s)
- Donal O'Shea
- Department of Endocrinology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Gallati S. Disease-modifying genes and monogenic disorders: experience in cystic fibrosis. APPLICATION OF CLINICAL GENETICS 2014; 7:133-46. [PMID: 25053892 PMCID: PMC4104546 DOI: 10.2147/tacg.s18675] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The mechanisms responsible for the determination of phenotypes are still not well understood; however, it has become apparent that modifier genes must play a considerable role in the phenotypic heterogeneity of Mendelian disorders. Significant advances in genetic technologies and molecular medicine allow huge amounts of information to be generated from individual samples within a reasonable time frame. This review focuses on the role of modifier genes using the example of cystic fibrosis, the most common lethal autosomal recessive disorder in the white population, and discusses the advantages and limitations of candidate gene approaches versus genome-wide association studies. Moreover, the implications of modifier gene research for other monogenic disorders, as well as its significance for diagnostic, prognostic, and therapeutic approaches are summarized. Increasing insight into modifying mechanisms opens up new perspectives, dispelling the idea of genetic disorders being caused by one single gene.
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Affiliation(s)
- Sabina Gallati
- Division of Human Genetics, Department of Pediatrics, and Department of Clinical Research, Inselspital, University of Berne, Berne, Switzerland
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Kelly A, Moran A. Corrigendum to: “Update on cystic fibrosis-related diabetes” [Journal of Cystic Fibrosis 12 (2013) 318-331]. J Cyst Fibros 2014. [DOI: 10.1016/j.jcf.2013.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Basile KJ, Johnson ME, Xia Q, Grant SFA. Genetic susceptibility to type 2 diabetes and obesity: follow-up of findings from genome-wide association studies. Int J Endocrinol 2014; 2014:769671. [PMID: 24719615 PMCID: PMC3955626 DOI: 10.1155/2014/769671] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 01/17/2014] [Accepted: 01/20/2014] [Indexed: 12/13/2022] Open
Abstract
Elucidating the underlying genetic variations influencing various complex diseases is one of the major challenges currently facing clinical genetic research. Although these variations are often difficult to uncover, approaches such as genome-wide association studies (GWASs) have been successful at finding statistically significant associations between specific genomic loci and disease susceptibility. GWAS has been especially successful in elucidating genetic variants that influence type 2 diabetes (T2D) and obesity/body mass index (BMI). Specifically, several GWASs have confirmed that a variant in transcription factor 7-like 2 (TCF7L2) confers risk for T2D, while a variant in fat mass and obesity-associated protein (FTO) confers risk for obesity/BMI; indeed both of these signals are considered the most statistically associated loci discovered for these respective traits to date. The discovery of these two key loci in this context has been invaluable for providing novel insight into mechanisms of heritability and disease pathogenesis. As follow-up studies of TCF7L2 and FTO have typically lead the way in how to follow up a GWAS discovery, we outline what has been learned from such investigations and how they have implications for the myriad of other loci that have been subsequently reported in this disease context.
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Affiliation(s)
- Kevin J. Basile
- Division of Human Genetics, The Children's Hospital of Philadelphia Research Institute, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Matthew E. Johnson
- Division of Human Genetics, The Children's Hospital of Philadelphia Research Institute, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Qianghua Xia
- Division of Human Genetics, The Children's Hospital of Philadelphia Research Institute, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Struan F. A. Grant
- Division of Human Genetics, The Children's Hospital of Philadelphia Research Institute, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
- Center for Applied Genomics, The Children's Hospital of Philadelphia Research Institute, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- 1216F Children's Hospital of Philadelphia Research Institute, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA
- *Struan F. A. Grant:
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Middleton PG, Wagenaar M, Matson AG, Craig ME, Holmes-Walker DJ, Katz T, Hameed S. Australian standards of care for cystic fibrosis-related diabetes. Respirology 2013; 19:185-192. [DOI: 10.1111/resp.12227] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 10/08/2013] [Accepted: 11/12/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Maria E. Craig
- Sydney Children's Hospital Network (Westmead); Sydney New South Wales Australia
| | | | - Tamarah Katz
- Sydney Children's Hospital Network; Sydney New South Wales Australia
| | - Shihab Hameed
- Sydney Children's Hospital Network; Sydney New South Wales Australia
- School of Women's and Children's Health; Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
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Affiliation(s)
- David Meyre
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
- Corresponding author: David Meyre,
| | - Guillaume Pare
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
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