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Takasawa K, Iemura R, Orimoto R, Yamano H, Kirino S, Adachi E, Saito Y, Yamamoto K, Matsuda N, Takishima S, Shuno K, Tajima H, Sugie M, Mizuno Y, Sutani A, Okamoto K, Masue M, Morio T, Kashimada K. Clinical management of diazoxide-unresponsive congenital hyperinsulinism: A single-center experience. Clin Pediatr Endocrinol 2024; 33:187-194. [PMID: 38993725 PMCID: PMC11234188 DOI: 10.1297/cpe.2024-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 05/07/2024] [Indexed: 07/13/2024] Open
Abstract
The most common cause of persistent hypoglycemia in newborns and children is congenital hyperinsulinism (CHI). Remarkable advancements in diagnostic tools and treatments, including novel imaging and genetic techniques, and continuous subcutaneous octreotide administration, have improved the prognosis of diazoxide-unresponsive CHI; however, in clinical practice, some issues remain. Here, we report a case series consisting of four adenosine triphosphate-sensitive potassium-associated CHI cases, discuss the practical use of new international guidelines published in 2023, and suggest clinical issues associated with CHI management. Based on the clinical experience of two diffuse and two focal CHI cases, we employed an updated treatment strategy, including genetic diagnosis to determine treatment plans, careful catheter management, switching from octreotide to long-acting somatostatin, effective utilization of a continuous glucose monitoring (CGM) device, measures for feeding problems, and individualized and systematic developmental follow-up. Particularly, our cases suggest a safe method of switching from octreotide to lanreotide, elucidate the efficacy of home-based CGM monitoring, and indicate need for personalized support for feeding problems. Severe CHI is a rare and challenging disorder; thus, further accumulation of experience according to new treatment strategies is essential in generating high-quality evidence for the development and approval of new treatment options.
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Affiliation(s)
- Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryosei Iemura
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuta Orimoto
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Haruki Yamano
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shizuka Kirino
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Eriko Adachi
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoko Saito
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
- Division of Medical Genetics, Kanagawa Children's Medical Center, Yokohama, Japan
| | - Kurara Yamamoto
- Department of Human Pathology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Nozomi Matsuda
- Department of Pediatrics, Soka Municipal Hospital, Saitama, Japan
| | | | - Kumi Shuno
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Hanako Tajima
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
| | - Manabu Sugie
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yuki Mizuno
- Department of Pediatric Surgery, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Akito Sutani
- Department of Pediatrics, Kawaguchi Municipal Medical Center, Saitama, Japan
| | - Kentaro Okamoto
- Department of Pediatric Surgery, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Michiya Masue
- Department of Pediatrics, Central Japan International Medical Center, Gifu, Japan
| | - Tomohiro Morio
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenichi Kashimada
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
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ElSheikh A, Driggers CM, Shyng SL. Non-radioactive Rb + Efflux Assay for Screening K ATP Channel Modulators. Methods Mol Biol 2024; 2796:191-210. [PMID: 38856903 DOI: 10.1007/978-1-0716-3818-7_12] [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] [Indexed: 06/11/2024]
Abstract
ATP-sensitive potassium (KATP) channels function as metabolic sensors that link cell membrane excitability to the cellular energy status by controlling potassium ion (K+) flow across the cell membrane according to intracellular ATP and ADP concentrations. As such, KATP channels influence a broad spectrum of physiological processes, including insulin secretion and cardiovascular functions. KATP channels are hetero-octamers, consisting of four inward rectifier potassium channel subunits, Kir6.1 or Kir6.2, and four sulfonylurea receptors (SURs), SUR1, SUR2A, or SUR2B. Different Kir6 and SUR isoforms assemble into KATP channel subtypes with distinct tissue distributions and physiological functions. Mutations in the genes encoding KATP channel subunits underlie various human diseases. Targeted treatment for these diseases requires subtype-specific KATP channel modulators. Rubidium ions (Rb+) also pass through KATP channels, and Rb+ efflux assays can be used to assess KATP channel function and activity. Flame atomic absorption spectroscopy (Flame-AAS) combined with microsampling can measure Rb+ in small volume, which provides an efficient tool to screen for compounds that alter KATP channel activity in Rb+ efflux assays. In this chapter, we describe a detailed protocol for Rb+ efflux assays designed to identify new KATP channel modulators with potential therapeutic utilities.
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Affiliation(s)
- Assmaa ElSheikh
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health and Science University, Portland, OR, USA.
- Department of Medical Biochemistry, Tanta University, Tanta, Egypt.
| | - Camden M Driggers
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Show-Ling Shyng
- Department of Chemical Physiology and Biochemistry, School of Medicine, Oregon Health and Science University, Portland, OR, USA
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3
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Alam KA, Svalastoga P, Martinez A, Glennon JC, Haavik J. Potassium channels in behavioral brain disorders. Molecular mechanisms and therapeutic potential: A narrative review. Neurosci Biobehav Rev 2023; 152:105301. [PMID: 37414376 DOI: 10.1016/j.neubiorev.2023.105301] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023]
Abstract
Potassium channels (K+-channels) selectively control the passive flow of potassium ions across biological membranes and thereby also regulate membrane excitability. Genetic variants affecting many of the human K+-channels are well known causes of Mendelian disorders within cardiology, neurology, and endocrinology. K+-channels are also primary targets of many natural toxins from poisonous organisms and drugs used within cardiology and metabolism. As genetic tools are improving and larger clinical samples are being investigated, the spectrum of clinical phenotypes implicated in K+-channels dysfunction is rapidly expanding, notably within immunology, neurosciences, and metabolism. K+-channels that previously were considered to be expressed in only a few organs and to have discrete physiological functions, have recently been found in multiple tissues and with new, unexpected functions. The pleiotropic functions and patterns of expression of K+-channels may provide additional therapeutic opportunities, along with new emerging challenges from off-target effects. Here we review the functions and therapeutic potential of K+-channels, with an emphasis on the nervous system, roles in neuropsychiatric disorders and their involvement in other organ systems and diseases.
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Affiliation(s)
| | - Pernille Svalastoga
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway; Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | | | - Jeffrey Colm Glennon
- Conway Institute for Biomolecular and Biomedical Research, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Jan Haavik
- Department of Biomedicine, University of Bergen, Norway; Division of Psychiatry, Haukeland University Hospital, Norway.
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Perge K, Nicolino M. Variable phenotypes of individual and family monogenic cases with hyperinsulinism and diabetes: a systematic review. Rev Endocr Metab Disord 2022; 23:1063-1078. [PMID: 35996042 DOI: 10.1007/s11154-022-09749-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
Maturity-Onset Diabetes of the Youth (MODY) diabetes remains commonly misdiagnosed. A monogenic form should be suspected in individuals presenting hyperinsulinemic hypoglycemia (HH) associated with, either later development of MODY (hypoglycemia-remission-diabetes sequence), or with first/second-degree family history of diabetes. Herein, we aimed to describe this individual or family monogenic association between HH and diabetes, and identify potential genotype-phenotype correlations. We conducted a systematic review of 26 studies, including a total of 67 patients with this association resulting from variants in GCK (n = 5 cases), ABCC8 (n = 29), HNF1A (n = 5), or HNF4A (n = 28). A family history of hypoglycemia and/or diabetes was present in 91% of cases (61/67). Median age at first hypoglycemia was 24 h after birth. Diazoxide was initiated in 46 children (46/67-69%); responsiveness was found in 91% (42/46). Median HH duration was three years (1 day-25 years). Twenty-three patients (23/67-34%) later developed diabetes (median age: 13 years; range: 8-48); more frequently in those untreated with diazoxide. This association was most commonly inherited in an autosomal dominant manner (43/48-90%). Some genes were associated with less severe initial hypoglycemia (HNF1A), shorter duration of HH (HNF4A), and more maternal (ABCC8) or paternal (HNF4A) transmission. This study illustrates that the same genotype can give a biphasic phenotype in the same person or a reverse phenotype in the same family. Wider awareness of this association is necessary in pediatrics to establish annual monitoring of patients who have presented HH, and during maternity to screen diabetes and optimize genetic counseling and management of pregnancy, childbirth, and the newborn.PROSPERO registration: CRD42020178265.
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Affiliation(s)
- Kevin Perge
- Service d'Endocrinologie Pédiatrique Et Pédiatrie Générale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677, Bron, France
- Université Claude Bernard, Lyon 1, 8 Avenue Rockefeller, 69008, Lyon, France
| | - Marc Nicolino
- Service d'Endocrinologie Pédiatrique Et Pédiatrie Générale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, 59 Boulevard Pinel, 69677, Bron, France.
- Université Claude Bernard, Lyon 1, 8 Avenue Rockefeller, 69008, Lyon, France.
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Vossschulte H, Mohnike K, Mohnike K, Warncke K, Akcay A, Zenker M, Wieland I, Schanze I, Hoefele J, Förster C, Barthlen W, Stahlberg K, Empting S. Correlation of PET-MRI, pathology, LOH and surgical success in a case of CHI with atypical large pancreatic focus. J Endocr Soc 2022; 6:bvac056. [PMID: 35475025 PMCID: PMC9032632 DOI: 10.1210/jendso/bvac056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Indexed: 11/19/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a rare cause of severe hypoglycemia in newborns. In focal CHI, usually one activity peak in fluorine-18-L-dihydroxyphenylalanine (18F-DOPA) positron emission tomography–magnetic resonance imaging (PET-MRI) indicates one focal lesion and its resection results in cure of the child. We present the case of a 5-month-old girl with CHI. Mutational screening of genes involved in CHI revealed a heterozygous pathogenic variant in the ABCC8 gene, which was not detectable in the parents. 18F-DOPA PET-MRI revealed 2 distinct activity peaks nearby in the pancreatic body and neck. Surgical resection of the tissue areas representing both activity peaks resulted in long-lasting normoglycemia that was proven by a fasting test. Molecular analysis of tissue samples from various sites provided evidence that a single second genetic hit in a pancreatic precursor cell was responsible for the atypical extended pancreatic lesion. There was a close correlation in the resected areas of PET-MRI activity with focal histopathology and frequency of the mutant allele (loss of heterozygosity) in the tissue. Focal lesions can be very heterogenous. The resection of the most affected areas as indicated by imaging, histopathology, and genetics could result in complete cure.
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Affiliation(s)
- Hendrik Vossschulte
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Germany
| | | | - Klaus Mohnike
- University Children’s Hospital, Otto-von-Guericke University Magdeburg, Germany
| | - Katharina Warncke
- Department of Pediatrics, Kinderklinik München Schwabing, Technical University of Munich, School of Medicine, Munich, Germany
| | - Ayse Akcay
- Department of Neonatology, Munich-Schwabing Municipal Hospitals, Munich, Germany
| | - Martin Zenker
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Germany
| | - Ilse Wieland
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Germany
| | - Ina Schanze
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Germany
| | - Julia Hoefele
- Institute of Human Genetics, Klinikum rechts der Isar, Technical University of Munich, School of Medicine, Munich, Germany
| | - Christine Förster
- Institute of Pathology, Hospital Nordstadt, affiliated with the University Hospital of the University of Bielefeld, Campus Bielefeld Bethel, Hanover, Germany
| | - Winfried Barthlen
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Germany
| | - Kim Stahlberg
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, Campus Bielefeld Bethel, University of Bielefeld, Germany
| | - Susann Empting
- University Children’s Hospital, Otto-von-Guericke University Magdeburg, Germany
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Sirolimus in infants with congenital hyperinsulinism (CHI) - a single-centre experience. Eur J Pediatr 2022; 181:407-412. [PMID: 34304300 DOI: 10.1007/s00431-021-04209-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycaemia in neonates and infants. Medical treatment includes the use of high concentrations of glucose and combinations of diazoxide, octreotide and glucagon. We report our experience of using sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, in the treatment of CHI in seven newborns who are poorly responding to standard medical therapy. Majority (87%) of infants achieved euglycaemia using a combination of oral feeding and the addition of sirolimus to standard medical treatment. One infant who failed to achieve euglycaemia even after surgery managed successfully with sirolimus. Diagnosis was confirmed by genetics evaluation; in three infants, novel mutations were detected. Outcome and long-term follow-up of all cases are described.Conclusion: Sirolimus can be considered in treatment of CHI refractory to standard medical treatment or in cases unresponsive to surgical treatment. What is Known: • Congenital hyperinsulinism (CHI) or persistent hyperinsulinaemic hypoglycaemia of infancy (PHHI) associated with mutations such as the ABBC8 or KCNJ gene known to cause hypoglycaemia refractory to standard medical treatment such as diazoxide and octreotide and may need subtotal pancreatectomy (STP). • Sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, was recently reported to be useful for refractory CHI cases with variable efficacy. What is New: • Our case series describes efficacy and safety of sirolimus in seven genetically proven refractory CHI cases with mainly neonatal presentation. All patients' follow-ups are described. • Out of seven infants, six infants responded well to sirolimus, and among these one infant who failed to respond to surgery (STP) also successfully managed with sirolimus. • It highlights the right patient selection and right dose to successfully manage these cases without much adverse effects.
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7
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States LJ, Davis JC, Hamel SM, Becker SA, Zhuang H. 18F-6-Fluoro-l-Dopa PET/CT Imaging of Congenital Hyperinsulinism. J Nucl Med 2021; 62:51S-56S. [PMID: 34230074 DOI: 10.2967/jnumed.120.246033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/08/2020] [Indexed: 11/16/2022] Open
Abstract
Congenital hyperinsulinism is characterized by persistent hypoglycemia due to inappropriate excess secretion of insulin resulting in hyperinsulinemic hypoglycemia. The clinical course varies from mild to severe, with a significant risk for brain damage. Imaging plays a valuable role in the care of infants and children with severe hypoglycemia unresponsive to medical therapy. 18F-6-fluoro-l-dopa PET/CT is the method of choice for the detection and localization of a focal lesion of hyperinsulinism. Surgical resection of a focal lesion can lead to a cure with limited pancreatectomy. This article reviews the role of 18F-6-fluoro-l-dopa PET/CT in the management of this vulnerable population.
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Affiliation(s)
- Lisa J States
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and
| | - J Christopher Davis
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and
| | - Steven M Hamel
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Susan A Becker
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Hongming Zhuang
- Radiology Department, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, and
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States LJ, Saade-Lemus S, De Leon DD. 18-F-L 3,4-Dihydroxyphenylalanine PET/Computed Tomography in the Management of Congenital Hyperinsulinism. PET Clin 2021; 15:349-359. [PMID: 32498990 DOI: 10.1016/j.cpet.2020.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Congenital hyperinsulinism (HI) is the most common cause of persistent hypoglycemia in neonates and infants. Several genetic mutations have been identified and are associated with 2 distinct histopathologic forms of disease: diffuse and focal. Targeted clinical evaluation to distinguish medically treatable disease from disease requiring surgical management can prevent life-threatening complications. Detection and localization of a surgically curable focal lesion using PET imaging with 18-F-L 3,4-dihydroxyphenylalanine ([18F]-FDOPA) has become standard of care. This article provides guidelines for the selection of patients who can benefit from [18F]-FDOPA-PET/computed tomography and protocols and tips used to diagnose a focal lesion of HI.
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Affiliation(s)
- Lisa J States
- Section of Oncologic Imaging, Radiology Department, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Sandra Saade-Lemus
- Section of Oncologic Imaging, Radiology Department, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; The Roberts Center for Pediatric Research, Room 8255, 2715 South Street, Philadelphia, PA 19146, USA
| | - Diva D De Leon
- Perelman School of Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA; Division of Endocrinology and Diabetes, Congenital Hyperinsulinism Center, The Children's Hospital of Philadelphia, 3500 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Braune K, Wäldchen M, Raile K, Hahn S, Ubben T, Römer S, Hoeber D, Reibel NJ, Launspach M, Blankenstein O, Bührer C. Open-Source Technology for Real-Time Continuous Glucose Monitoring in the Neonatal Intensive Care Unit: Case Study in a Neonate With Transient Congenital Hyperinsulinism. J Med Internet Res 2020; 22:e21770. [PMID: 33275114 PMCID: PMC7748959 DOI: 10.2196/21770] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 09/15/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Use of real-time continuous glucose monitoring (rtCGM) systems has been shown to be a low-pain, safe, and effective method of preventing hypoglycemia and hyperglycemia in people with diabetes of various age groups. Evidence on rtCGM use in infants and in patients with conditions other than diabetes remains limited. OBJECTIVE This case study describes the off-label use of rtCGM and the use of an open-source app for glucose monitoring in a newborn with prolonged hypoglycemia secondary to transient congenital hyperinsulinism during the perinatal period. METHODS The Dexcom G6 rtCGM system (Dexcom, Inc) was introduced at 39 hours of age. Capillary blood glucose checks were performed regularly. In order to benefit from customizable alert settings and detect hypoglycemic episodes, the open-source rtCGM app xDrip+ was introduced at 9 days of age. RESULTS Time in range (45-180 mg/dL) for interstitial glucose remained consistently above 90%, whereas time in hypoglycemia (<45 mg/dL) decreased. Mean glucose was maintained above 70 mg/dL at 72 hours of life and thereafter. Daily sensor glucose profiles showed cyclic fluctuations that were less pronounced over time. CONCLUSIONS While off-label use of medication is both common practice and a necessity in newborn infants, there are few examples of off-label uses of medical devices, rtCGM being a notable exception. Real-time information allowed us to better understand glycemic patterns and to improve the quality of glycemic control accordingly. Severe hypoglycemia was prevented, and measurement of serum levels of insulin and further lab diagnostics were performed much faster, while the patient's individual burden caused by invasive procedures was reduced. Greater customizability of threshold and alert settings would be beneficial for user groups with glycemic instability other than people with diabetes, and for hospitalized newborn infants in particular. Further research in the field of personal and off-label rtCGM use, efficacy studies evaluating the accuracy of low glucose readings, and studies on the differences between algorithms in translating raw sensor data, as well as customization of commercially available rtCGM systems, is needed.
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Affiliation(s)
- Katarina Braune
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Mandy Wäldchen
- School of Sociology, University College Dublin, Belfield, Ireland
| | - Klemens Raile
- Charité - Universitätsmedizin Berlin, Department of Paediatric Endocrinology and Diabetes, Berlin, Germany
| | - Sigrid Hahn
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
| | - Tebbe Ubben
- #dedoc° Diabetes Online Community, Dedoc Labs GmbH, Berlin, Germany
| | - Susanne Römer
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
| | - Daniela Hoeber
- Charité - Universitätsmedizin Berlin, Department of Paediatric Gastroenterology, Nephrology and Metabolic Diseases, Berlin, Germany
| | - Nora Johanna Reibel
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
| | - Michael Launspach
- Berlin Institute of Health, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
| | - Oliver Blankenstein
- Charité - Universitätsmedizin Berlin, Institute for Experimental Paediatric Endocrinology, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Newborn Screening Laboratory, Berlin, Germany
| | - Christoph Bührer
- Charité - Universitätsmedizin Berlin, Department of Neonatology, Berlin, Germany
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Garg PK, Putegnat B, Truong L, Reynolds C, Sanchez I, Nedrelow JK, Uffman J, Lokitz SJ, Nazih R, Garg S, Thornton PS. Visual interpretation, not SUV ratios, is the ideal method to interpret 18F-DOPA PET scans to aid in the cure of patients with focal congenital hyperinsulinism. PLoS One 2020; 15:e0241243. [PMID: 33108363 PMCID: PMC7591017 DOI: 10.1371/journal.pone.0241243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/11/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Congenital hyperinsulinism is characterized by abnormal regulation of insulin secretion from the pancreas causing profound hypoketotic hypoglycemia and is the leading cause of persistent hypoglycemia in infants and children. The main objective of this study is to highlight the different mechanisms to interpret the 18F-DOPA PET scans and how this can influence outcomes. MATERIALS AND METHODS After 18F-Fluoro-L-DOPA was injected intravenously into 50 subjects' arm at a dose of 2.96-5.92 MBq/kg, three to four single-bed position PET scans were acquired at 20, 30, 40 and 50-minute post injection. The radiologist interpreted the scans for focal and diffuse hyperinsulinism using a visual interpretation method, as well as determining the Standard Uptake Value ratios with varying cut-offs. RESULTS Visual interpretation had the combination of the best sensitivity and positive prediction values. CONCLUSIONS In patients with focal disease, SUV ratios are not as accurate in identifying the focal lesion as visual inspection, and cases of focal disease may be missed by those relying on SUV ratios, thereby denying the patients a chance of cure. We recommend treating patients with diazoxide-resistant hyperinsulinism in centers with dedicated multidisciplinary team comprising of at least a pediatric endocrinologist with a special interest in hyperinsulinism, a radiologist experienced in interpretation of 18F-Fluoro-L-DOPA PET/CT scans, a histopathologist with experience in frozen section analysis of the pancreas and a pancreatic surgeon experienced in partial pancreatectomies in patients with hyperinsulinism.
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Affiliation(s)
- Pradeep K. Garg
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
- * E-mail:
| | - Burton Putegnat
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Lisa Truong
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Courtney Reynolds
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Irene Sanchez
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | | | - John Uffman
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
| | - Stephen J. Lokitz
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Rachid Nazih
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Sudha Garg
- Center for Molecular Imaging and Therapy, Biomedical Research Foundation, Shreveport, Louisiana, United States of America
| | - Paul S. Thornton
- Cook Children’s Medical Center, Fort Worth, Texas, United States of America
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11
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Papel de la PET/TC con 18F-DOPA en el diagnóstico de la forma congénita focal del hiperinsulinismo en niños. Rev Esp Med Nucl Imagen Mol 2020. [DOI: 10.1016/j.remnie.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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12
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Al Azmi F, Al Shaikh A. Persistent Hypoglycemia in Seven-year-old Saudi Child: A Case Report. Oman Med J 2020; 35:e154. [PMID: 32802414 PMCID: PMC7417511 DOI: 10.5001/omj.2020.75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 12/23/2019] [Indexed: 11/03/2022] Open
Abstract
Hypoglycemia is a frequent problem in infants and children, causing a significant dilemma to reach the correct diagnosis and perform the appropriate management. Congenital hyperinsulinism is the most common cause of hypoglycemic hyperinsulinemia in infants and is due to beta-cell hyperplasia caused by genetic defects. This is a well-known genetically and clinically heterogeneous condition causing severe hypoglycemia in infants. Insulin-secreting tumors (insulinoma) are rare findings during childhood. In contrast, insulinoma is the most common form of endogenous hypoglycemic hyperinsulinemia in the adult population. Here we present a successful diagnosis and treatment of a nine-year-old Saudi child who presented for the first time with severe episodes of hypoglycemia at age seven. Critical samples at the time of hypoglycemia confirmed the associated hyperinsulinemia state. Initially, the child responded well to anti-insulin medications at small doses, but with time the disease became progressive in severity requiring a high dose of anti-insulin medications, frequent glucagon injections, and hospital admission for intravenous dextrose infusion. After two years of seeking therapy in many hospitals, the final diagnosis was confirmed to be an insulinoma, which was removed surgically, resulting in a complete cure and full recovery. Here we report the first published case of insulinoma in a young child aged < 15 years old in Saudi Arabia, their disease course, final diagnostic steps, and curative therapy. We conclude that hypoglycemia in children is challenging in terms of diagnosis and management. Although insulinoma is very rare in children, it requires significant time and effort by a pediatrician, pediatric endocrinologist, patients, and parents to reach the final diagnosis and carefully preserve the integrity of the neurological state of those children.
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Affiliation(s)
- Fayez Al Azmi
- Division of Endocrinology, Pediatric Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs,
King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Adnan Al Shaikh
- Division of Endocrinology, Pediatric Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs,
King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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The role of 18F-DOPA PET/CT in the diagnosis of the congenital focal form of hyperinsulinism in children. Rev Esp Med Nucl Imagen Mol 2020; 39:279-283. [PMID: 32448747 DOI: 10.1016/j.remn.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 01/15/2020] [Accepted: 02/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) is a neuroendocrine disease with focal or diffuse abnormalities in pancreas. While drug-resistant diffuse forms require near-total pancreatectomy or prolonged pharmacotherapy, focal CHI may be treated by targeted surgical resection. We evaluated the usefulness of 18F-DOPA PET/CT to identify the focal pancreatic form. SUBJECTS AND METHODS Nineteen children (11 boys, 8 girls, aged 2-54 months) with clinical signs of neonatal CHI and positive genetic examinations were enrolled in the study. After i.v. administration of 18F-DOPA, early PET and late PET/CT acquisition covering one-bed length over thoraco-abdominal region were performed. Both acquisitions were done in dynamic mode to allow exclusion of frames with motion artefacts. Standardized uptake values were adjusted to bodyweight (SUVbw). The finding was considered as focal when the ratio of SUVbwmax between the suspicious region and the rest of pancreas was greater than 1.2. RESULTS Focal forms were recorded in 10/19 children and 4 of them underwent surgical resection with complete recovery. Focal uptake was significantly higher than the uptake in the normal pancreatic tissue (p=0.0059). Focal and diffuse forms of CHI did not differ significantly in normal pancreatic tissue uptake. We found no advantage in the measurement of SUVbwmean ratio compared to SUVbwmax ratio (p=0.50). CONCLUSION 18F-DOPA PET/CT is a useful tool for the localization of focal CHI and planning of surgical treatment.
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Rasmussen AG, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Rasmussen AH, Mortensen MB, Christesen HT. The difficult management of persistent, non-focal congenital hyperinsulinism: A retrospective review from a single, tertiary center. Pediatr Diabetes 2020; 21:441-455. [PMID: 31997554 DOI: 10.1111/pedi.12989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 11/14/2019] [Accepted: 01/13/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Congenital hyperinsulinism (CHI) is a rare, heterogeneous disease with transient or persistent hypoglycemia. Histologically, focal, diffuse, and atypical forms of CHI exist, and at least 11 disease-causing genes have been identified. METHODS We retrospectively evaluated the treatment and outcome of a cohort of 40 patients with non-focal, persistent CHI admitted to the International Hyperinsulinism Center, Denmark, from January 2000 to May 2017. RESULTS Twenty-two patients (55%) could not be managed with medical monotherapy (diazoxide or octreotide) and six (15%) patients developed severe potential side effects to medication. Surgery was performed in 17 (43%) patients with resection of 66% to 98% of the pancreas. Surgically treated patients had more frequently KATP -channel gene mutations (surgical treatment 12/17 vs conservative treatment 6/23, P = .013), highly severe disease (15/17 vs 13/23, P = .025) and clinical onset <30 days of age (15/17 vs 10/23, P = .004). At last follow-up at median 5.3 (range: 0.3-31.3) years of age, 31/40 (78%) patients still received medical treatment, including 12/17 (71%) after surgery. One patient developed diabetes after a 98% pancreatic resection. Problematic treatment status was seen in 7/40 (18%). Only 8 (20%) had clinical remission (three spontaneous, five after pancreatic surgery). Neurodevelopmental impairment (n = 12, 30%) was marginally associated with disease severity (P = .059). CONCLUSIONS Persistent, non-focal CHI remains difficult to manage. Neurological impairment in 30% suggests a frequent failure of prompt and adequate treatment. A high rate of problematic treatment status at follow-up demonstrates an urgent need for new medical treatment modalities.
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Affiliation(s)
- Amalie G Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Melikian
- Department of Pediatric Endocrinology, Endrocrine Research Center, Moscow, Russia
| | - Evgenia Globa
- Department of Pediatric Endocrinology, Ukrainian Research Center of Endocrine Surgery, Kyiv, Ukraine
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Annett H Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Michael B Mortensen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik T Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark
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Radionuclide Imaging of Children. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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16
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Siersbæk J, Larsen AR, Nybo M, Christesen HT. A Sensitive Plasma Insulin Immunoassay to Establish the Diagnosis of Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2020; 11:614993. [PMID: 33679602 PMCID: PMC7935514 DOI: 10.3389/fendo.2020.614993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/31/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The diagnosis of congenital hyperinsulinism (CHI) may be hampered by a plasma (p-) insulin detection limit of 12-18 pmol/L (2-3 mU/L). OBJECTIVE To evaluate the diagnostic performance of a sensitive insulin immunoassay and to find the optimal p-insulin cut-off for the diagnosis of CHI. METHODS Diagnostic fasting tests, performed without medication or i.v.-glucose, were investigated in children with a clinical diagnosis of CHI, or idiopathic ketotic hypoglycemia (IKH). The CHI diagnosis was either clinical or by the alternative, p-insulin-free criteria; hypoglycemia plus disease-causing genetic mutations and/or CHI-compatible pancreatic histopathology. We included diagnostic p-insulin samples with simultaneous p-glucose <3.2 mmol/L and used a sensitive insulin assay (Cobas e411 immunoassay analyzer; lower detection limit 1.2 pmol/L; normal range 15.1-147.1 pmol/L). Receiver operating characteristics area under the curve (ROC AUC) values and optimal cut-offs were analyzed for the performance of p-insulin to diagnose CHI. RESULTS In 61 CHI patients, the median (range) p-insulin was 76.5 (17-644) pmol/L compared to 1.5 (1.5-7.7) pmol/L in IKH patients (n=15). The ROC AUC was 1.0 for the diagnosis of CHI defined both by the clinical diagnosis (n=61) and by alternative criteria (n=57). The optimal p-insulin cut-offs were 12.3 pmol/L, and 10.6 pmol/L, at p-glucose <3.2 mmol/L (n=61), and <3.0 mmol/L (n=49), respectively. CONCLUSIONS The sensitive insulin assay performed excellent in diagnosing CHI with optimal p-insulin cut-offs at 12.3 pmol/L (2.0 mU/L), and 10.6 pmol/L (1.8 mU/L), at p-glucose <3.2 mmol/L, and <3.0 mmol/L, respectively. A sensitive insulin assay may serve to simplify the diagnosis of CHI.
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Affiliation(s)
- Julie Siersbæk
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Annette Rønholt Larsen
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- *Correspondence: Henrik Thybo Christesen,
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Current and Emerging Agents for the Treatment of Hypoglycemia in Patients with Congenital Hyperinsulinism. Paediatr Drugs 2019; 21:123-136. [PMID: 31218604 DOI: 10.1007/s40272-019-00334-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycmia in neonatles and children. The inappropriate secretion of insulin by the pancreatic β-cells produces recurrent hypoglycemia, which can lead to severe and permanent brain damage. CHI results from mutations in different genes that play a role in the insulin secretion pathway, and each differs in their responsiveness to medical treatment. Currently, the only available approved treatment for hyperinsulinism is diazoxide. Patients unresponsive to diazoxide may benefit from specialized evaluation including genetic testing and 18F-DOPA PET to identify those with focal forms of CHI. The focal forms can be cured by selective pancreatectomy, but the management of diazoxide-unresponsive diffuse CHI is a real therapeutic challenge. Current off-label therapies include intravenous glucagon, octreotide and long-acting somatostatin analogs; however, they are often insufficient, and a 98% pancreatectomy or continuous feeds may be required. For the first time in over 40 years, new drugs are being developed, but none have made it to market yet. In this review, we will discuss current on-label and off-label drugs and review the currently available data on the novel drugs under development.
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Sidler M, Shah P, Ashworth M, De Coppi P. Laparoscopic resection of pancreatic neck lesion with Roux-en-Y pancreatico-jejunostomy. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2019. [DOI: 10.1016/j.epsc.2018.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Ludwig A, Enke S, Heindorf J, Empting S, Meissner T, Mohnike K. Formal Neurocognitive Testing in 60 Patients with Congenital Hyperinsulinism. Horm Res Paediatr 2018; 89:1-6. [PMID: 29151084 DOI: 10.1159/000481774] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 09/25/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) is hallmarked by persistent hypoketotic hypoglycemia in infancy. In the majority of all patients, CHI is caused by mutations in the KATP channel genes ABCC8 and KCNJ11, but other genes in the insulin-regulatory pathway have also been described. Repeated episodes of hypoglycemia include an increased risk of seizures and intellectual disability. So far, controlled psychometric studies on cognitive, motor, speech, and social-emotional outcome of CHI patients are missing. Until now, neurodevelopmental long-term outcome in CHI patients has only been measured by questionnaires, self-, parental-, or caregiver-administered instruments. METHODS This is a prospective study of 60 patients (median age 3.3 years, range 3 months to 57 years): 48 with a diffuse, 9 with a focal, and 3 with an atypical histology. Neurodevelopmental outcome was assessed using standardized psychological tests and questionnaires. RESULTS 28 of 60 patients showed developmental delay (46.7%). 9 of 57 patients had cognitive deficits (15.8%), 7 of 26 patients had speech problems (26.9%), and 17 of 44 patients had motor problems (38.6%). In 5 of 53 patients, social-emotional problems were reported. Outcome and the underlying genetic defect were not correlated. CONCLUSIONS Motor problems seem to be prominent in CHI patients. Despite a high incidence of developmental delay, a permanent cognitive defect was only detectable in 9 of 58 patients.
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Affiliation(s)
- Anja Ludwig
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Simone Enke
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Janine Heindorf
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Susann Empting
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Thomas Meissner
- Department of Pediatrics, University Duesseldorf, Duesseldorf, Germany
| | - Klaus Mohnike
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
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Louvigne M, Rouleau S, Caldagues E, Souto I, Montcho Y, Bouvagnet AM, Baud O, Carel JC, Gascoin G, Coutant R. Association of maternal nutrition with transient neonatal hyperinsulinism. PLoS One 2018; 13:e0195383. [PMID: 29723237 PMCID: PMC5933751 DOI: 10.1371/journal.pone.0195383] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 03/21/2018] [Indexed: 11/22/2022] Open
Abstract
Objective The objective was to determine whether maternal nutritional factors are associated with transient neonatal hyperinsulinism (HI). Design and setting Case control study in 4 French tertiary Obstetrics and Neonatology Departments between 2008 and 2015. Methods Sixty-seven mothers of neonates diagnosed with transient hyperinsulinism and 113 mothers of controls were included. The screening for hyperinsulinemic hypoglycemia in neonates was performed because of clinical symptoms suggestive of hypoglycemia or in the presence of conventional risk factors (small-for-gestational-age, prematurity, anoxo-ischemia, hypothermia, macrosomia, gestational diabetes). Hyperinsulinemic hypoglycemia was confirmed in the HI neonates and ruled out in the controls. This allowed for comparing maternal nutrition in cases and controls in a context of similar risk factors. One to 2 mothers of control neonates were included per case, and a food frequency questionnaire was addressed to the mothers between day 5 and day 10 after the birth of their newborn. Results Crude odds ratio showed that maternal weight gain, abnormal fetal rate, C-section, gender, consumption of fresh cooked vegetables, fresh fruits and fruit juices, low fat diary products, light fat products, and daily bread were significantly associated with hyperinsulinism. Maternal body mass index, hypertension, gestational diabetes, birth weight percentile, gestational age and 5-minute Apgar score were not related to HI. In a multiple backward logistic regression model, consumption of fresh cooked vegetable ≥1/day (OR = 0.33 [0.14–0.77]) and light-fat products ≥1/week (OR = 0.24 [0.08–0.71]) was protective against hyperinsulinism, whereas gestational weight gain >20 kg (OR = 9.5 [2.0–45.5]) and between 15–20 kg (OR = 4.0 [1.2–14.0]), abnormal fetal heart rate (OR = 4.4 [1.6–12.0]), and C-section (OR = 3.4 [1.3–8.9]) were risk factors. Conclusions A diet rich in fresh cooked vegetable and reduced in fat, together with the avoidance of a high gestational weight gain may be protective against transient neonatal hyperinsulinism.
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Affiliation(s)
- Mathilde Louvigne
- Service de Diabétologie et Endocrinologie Pédiatrique, Departement de Pédiatrie, et Centre de Reference des Maladies Endocriniennes Rares de la Thyroïde et de l’Hypophyse, Centre Hospitalier Universitaire d’Angers, Angers, France
- Service de Pédiatrie, Centre Hospitalier du Mans, Le Mans, France
| | - Stephanie Rouleau
- Service de Diabétologie et Endocrinologie Pédiatrique, Departement de Pédiatrie, et Centre de Reference des Maladies Endocriniennes Rares de la Thyroïde et de l’Hypophyse, Centre Hospitalier Universitaire d’Angers, Angers, France
- Service de Réanimation et Médecine Néonatale, Centre Hospitalier Universitaire d’Angers, Angers, France
| | - Emmanuelle Caldagues
- Service de Diabétologie et Endocrinologie Pédiatrique, Service de Pédiatrie, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Isabelle Souto
- Service de Pédiatrie, Centre Hospitalier du Mans, Le Mans, France
| | - Yanis Montcho
- Service de Réanimation et Médecine Néonatale, Centre Hospitalier du Mans, Le Mans, France
| | | | - Olivier Baud
- Service de Réanimation et Pédiatrie Néonatale, Hôpital Universitaire Robert-Debré, Paris, France
| | - Jean Claude Carel
- Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Universitaire Robert-Debré, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Paris, France
| | - Geraldine Gascoin
- Service d'Endocrinologie Diabétologie Pédiatrique et Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Hôpital Universitaire Robert-Debré, Université Paris Diderot, Sorbonne Paris Cité, AP-HP, Paris, France
| | - Regis Coutant
- Service de Diabétologie et Endocrinologie Pédiatrique, Departement de Pédiatrie, et Centre de Reference des Maladies Endocriniennes Rares de la Thyroïde et de l’Hypophyse, Centre Hospitalier Universitaire d’Angers, Angers, France
- * E-mail:
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Timlin MR, Black AB, Delaney HM, Matos RI, Percival CS. Development of Pulmonary Hypertension During Treatment with Diazoxide: A Case Series and Literature Review. Pediatr Cardiol 2017. [PMID: 28642988 DOI: 10.1007/s00246-017-1652-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycemia in infancy. The mainstay of medical management for CHI is diazoxide. Diazoxide inhibits insulin release from the pancreas, but also causes smooth muscle relaxation and fluid retention so it is typically given with chlorothiazide. In July 2015, the FDA issued a drug safety communication warning that pulmonary hypertension (PH) had been reported in 11 infants being treated with diazoxide and that the PH resolved with withdrawal of diazoxide. All three of the cases in our hospital were admitted to the neonatal intensive care unit (NICU) for hypoglycemia. All patients received thorough radiologic and laboratory evaluations related to their diagnosis of CHI. All initially improved when diazoxide was initiated. Case 1 and case 3 were discharged from the NICU on diazoxide and chlorothiazide. Case 2 developed pulmonary hypertension while still in the NICU days after an increase in diazoxide dosing. Case 1 presented to the emergency room in respiratory distress shortly after discharge from the NICU with evidence of PH and heart failure. Case 3 presented to the emergency room after 2 weeks at home due to a home blood glucose reading that was low and developed PH and heart failure while an inpatient. Discontinuation of diazoxide led to resolution of all three patients' PH within approximately one week. The experience of our hospital indicates that pulmonary hypertension may be more common than previously thought in infants taking diazoxide. It is unclear if these symptoms develop slowly over time or if there is some other, as yet undescribed, trigger for the pulmonary hypertension. Our hospital's experience adds to the body of evidence and suggests these infants may benefit from more surveillance with echocardiography.
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Affiliation(s)
| | | | | | - Renée I Matos
- San Antonio Military Medical Center, San Antonio, USA
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Yorifuji T, Horikawa R, Hasegawa T, Adachi M, Soneda S, Minagawa M, Ida S, Yonekura T, Kinoshita Y, Kanamori Y, Kitagawa H, Shinkai M, Sasaki H, Nio M. Clinical practice guidelines for congenital hyperinsulinism. Clin Pediatr Endocrinol 2017; 26:127-152. [PMID: 28804205 PMCID: PMC5537210 DOI: 10.1297/cpe.26.127] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/08/2017] [Indexed: 12/11/2022] Open
Abstract
Congenital hyperinsulinism is a rare condition, and following recent advances in
diagnosis and treatment, it was considered necessary to formulate evidence-based clinical
practice guidelines reflecting the most recent progress, to guide the practice of
neonatologists, pediatric endocrinologists, general pediatricians, and pediatric surgeons.
These guidelines cover a range of aspects, including general features of congenital
hyperinsulinism, diagnostic criteria and tools for diagnosis, first- and second-line
medical treatment, criteria for and details of surgical treatment, and future
perspectives. These guidelines were generated as a collaborative effort between The
Japanese Society for Pediatric Endocrinology and The Japanese Society of Pediatric
Surgeons, and followed the official procedures of guideline generation to identify
important clinical questions, perform a systematic literature review (April 2016), assess
the evidence level of each paper, formulate the guidelines, and obtain public
comments.
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Affiliation(s)
- Tohru Yorifuji
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | | | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Shun Soneda
- Department of Pediatrics, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | - Shinobu Ida
- Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Takeo Yonekura
- Department of Pediatric Surgery, Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Kanamori
- Department of Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Hideyuki Sasaki
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
| | - Masaki Nio
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
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Maiorana A, Dionisi-Vici C. Hyperinsulinemic hypoglycemia: clinical, molecular and therapeutical novelties. J Inherit Metab Dis 2017; 40:531-542. [PMID: 28656511 DOI: 10.1007/s10545-017-0059-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/25/2017] [Accepted: 05/29/2017] [Indexed: 01/01/2023]
Abstract
Hyperinsulinemic hypoglycemia (HI) is the most common cause of hypoglycemia in children. Impairment of cellular pathways involved in insulin secretion from pancreatic β-cells, broadly classified as channelopathies and metabolopathies, have been discovered in the past two decades. The increasing use of NGS target panels, combined with clinical, biochemical and imaging findings allows differentiating the diagnostic management of children with focal forms, surgically curable, from those with diffuse forms, more conservatively treated with pharmacological and nutritional interventions. Specific approaches according to the subtype of HI have been established and novel therapies are currently under investigation. Despite diagnostic and therapeutic advances, HI remains an important cause of morbidity in children, still accounting for 26-44% of permanent intellectual disabilities, especially in neonatal-onset patients. Initial insult from recurrent hypoglycemia in early life greatly contributes to the poor outcomes. Therefore, patients need to be rapidly identified and treated aggressively, and require at follow-up a complex and regular monitoring, managed by a multidisciplinary HI team. This review gives an overview on the more recent diagnostic and therapeutic tools, on the novel drug and nutritional therapies, and on the long-term neurological outcomes.
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Affiliation(s)
- Arianna Maiorana
- Division of Metabolic Diseases, Department of Pediatric Specialties, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases, Department of Pediatric Specialties, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
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Corda H, Kummer S, Welters A, Teig N, Klee D, Mayatepek E, Meissner T. Treatment with long-acting lanreotide autogel in early infancy in patients with severe neonatal hyperinsulinism. Orphanet J Rare Dis 2017; 12:108. [PMID: 28576129 PMCID: PMC5455078 DOI: 10.1186/s13023-017-0653-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 05/12/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Treatment of severe diffuse congenital hyperinsulinism (CHI) without sufficient response to diazoxide is complicated by the lack of approved drugs. Therefore, patients are often hospitalized long-term or have to undergo pancreatic surgery if episodes of severe hypoglycaemia cannot be prevented. A long-acting somatostatin analogue, octreotide, has been reported to be an effective treatment option that prevents severe hypoglycaemia in children with CHI, and its off-label use is common in CHI. However, octreotide requires continuous i.v. or s.c. infusion or multiple daily injections. Here, we report our experiences with the use of a monthly application of a long-acting somatostatin analogue, lanreotide autogel® (LAN-ATG), in early infancy. RESULTS The mean blood glucose concentration within 7 days before the first LAN-ATG administration were compared to 7 days after the first LAN-ATG administration and increased by 0.75 mmol/L (range 0.39-1.19 mmol/L). In the following weeks intravenous glucose infusions, octreotide, and glucagon treatment could be successfully stopped in all patients 3-20 days after the first LAN-ATG injection without substantial worsening of the hypoglycaemia rate. Increased carbohydrate requirements could be normalized with an average reduction in the carbohydrate-intake of 7 g/kg body weight/d (range 1.75-12.8 g/kg body weight/d). Over a total of 52 treatment months, no serious adverse effects occurred. CONCLUSION Long-term LAN-ATG treatment improved blood glucose concentrations, lowered the frequency of hypoglycaemia or allowed for normalization of oral carbohydrate intake in infants with CHI younger than 6 months of age. No severe side effects were observed. LAN-ATG might be an alternative treatment option in infants with severe CHI who lack risk factors for necrotizing enterocolitis and are not responding to current treatment regimens as an alternative to surgery after careful individual evaluation.
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Affiliation(s)
- Heike Corda
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Germany.
| | - Sebastian Kummer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Germany
| | - Alena Welters
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Germany
| | - Norbert Teig
- University Children's Hospital, Katholisches Klinikum, Ruhr-Universität Bochum, Bochum, Germany
| | - Dirk Klee
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Duesseldorf, Duesseldorf, Germany
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Moorenstrasse 5, 40225, Duesseldorf, Germany
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Hambrook LE, Ciavarella AA, Nimmo JS, Wayne J. Hyperinsulinaemic, hypoglycaemic syndrome due to acquired nesidioblastosis in a cat. JFMS Open Rep 2017; 2:2055116916657846. [PMID: 28491431 PMCID: PMC5362857 DOI: 10.1177/2055116916657846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2016] [Indexed: 11/16/2022] Open
Abstract
Case summary A 6-year-old, neutered female British Shorthair cat presented with acute-onset weakness and mental dullness. Initially the cat was mildly hyperglycaemic (9.9 mmol/l; reference interval [RI] 3.3-6.7 mmol/l). Over the following 12 h the cat developed central blindness, tremors, intermittent seizures and opisthotonus. Repeat blood sampling revealed a marked hypoglycaemia (0.8 mmol/l). Insulin level (performed on a serum sample collected while the cat was hypoglycaemic) was inappropriately elevated (1575 mIU/l; RI 10-80 mIU/l). An abdominal ultrasound was unremarkable. An exploratory laparotomy revealed a firm and erythematous left limb of the pancreas. Following surgical resection of the left limb of the pancreas, the cat returned to a euglycaemic state after a brief rebound hyperglycaemia. Histopathology revealed pancreatic fibrosis with marked multifocal micronodular hyperplasia of exocrine and endocrine cells. Synaptophysin immunohistochemistry confirmed nodular β-cell hyperplasia. Relevance and novel information Nesidioblastosis describes a syndrome of acquired hyperinsulinaemia and associated hypoglycaemia secondary to focal or diffuse (non-neoplastic) β-cell hyperplasia within the pancreas. Acquired nesidioblastosis has been reported in humans, where β-cell dysregulation is thought to occur in response to pancreatic injury. This is the first reported case of clinically significant hypoglycaemia due to acquired nesidioblastosis in an adult domestic cat. While this condition is rare, nesidioblastosis is being increasingly recognised in humans and it is an important differential diagnosis to consider when investigating hypoglycaemia as it cannot be distinguished from insulinoma without histopathological evaluation. While recurrence has been occasionally reported in humans, the prognosis is considered good.
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Affiliation(s)
- Lydia E Hambrook
- Small Animal Medicine Department, Advanced Vetcare, Melbourne, VIC, Australia
| | - Amanda A Ciavarella
- Small Animal Medicine Department, Advanced Vetcare, Melbourne, VIC, Australia
| | - Judith S Nimmo
- Australian Specialised Animal Pathology Laboratory, Melbourne, VIC, Australia
| | - Julie Wayne
- Australian Specialised Animal Pathology Laboratory, Melbourne, VIC, Australia
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Abstract
Lower blood glucose values are common in the healthy neonate immediately after birth as compared to older infants, children, and adults. These transiently lower glucose values improve and reach normal ranges within hours after birth. Such transitional hypoglycemia is common in the healthy newborn. A minority of neonates experience a more prolonged and severe hypoglycemia, usually associated with specific risk factors and possibly a congenital hypoglycemia syndrome. Despite the lack of a specific blood glucose value that defines hypoglycemia, concern for substantial neurologic morbidity in the neonatal population has led to the generation of guidelines by both the American Academy of Pediatrics (AAP) and the Pediatric Endocrine Society (PES). Similarities between the 2 guidelines include recognition that the transitional form of neonatal hypoglycemia likely resolves within 48 hours after birth and that hypoglycemia that persists beyond that duration may be pathologic. One major difference between the 2 sets of guidelines is the goal blood glucose value in the neonate. This article reviews transitional and pathologic hypoglycemia in the neonate and presents a framework for understanding the nuances of the AAP and PES guidelines for neonatal hypoglycemia.
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Affiliation(s)
| | - Thomas Havranek
- Division of Neonatology, Children's Hospital at Montefiore, Bronx, NY
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27
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Pancreatic Uptake by 18F-FDOPA PET/CT in Patients With Hypoglycemia After Gastric Bypass Surgery Compared With Controls With or Without Carbidopa Pretreatment. Clin Nucl Med 2016; 42:163-168. [PMID: 28005639 DOI: 10.1097/rlu.0000000000001496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE The use of Fluorine-labeled dihydroxy-phenyl-alanine (F-FDOPA) PET/CT in patients with hypoglycemia suspected to be caused by pancreatic disease can be helpful to localize the source of excess insulin production. In this setting, carbidopa pretreatment is not recommended. However, quantitative comparisons of pancreatic tracer uptake in patients with or without carbidopa pretreatment and in diffuse pancreatic disease are lacking. Therefore, we aimed to describe and quantify pancreatic F-FDOPA uptake in patients without pancreatic disease with or without carbidopa pretreatment and in patients with hypoglycemia after gastric bypass surgery. PATIENTS AND METHODS This is a retrospective data analysis of F-FDOPA PET/CT scans performed at a university medical center in the period from 2009 to 2015. All scans were reconstructed and calculated based on the European Association of Nuclear Medicine/EANM Research Ltd guidelines. Of 358 patients without evidence of pancreatic disease or hypoglycemic disorders, 344 received carbidopa and 14 did not. Another 9 patients had post-gastric bypass hypoglycemia. The main outcome measurement was F-FDOPA SUVmax for pancreatic head, body, and tail regions. RESULTS Carbidopa pretreated patients had a lower median SUVmax (-1.15, -1.20, and -0.84 in pancreatic head, body, and tail [all P < 0.01]) than patients without carbidopa pretreatment. Patients with post-gastric bypass hypoglycemia scanned without carbidopa pretreatment had higher median SUVmax (+1.18, +1.39, and +1.63, all P < 0.03) compared with controls without pretreatment. CONCLUSIONS Patients with post-gastric bypass hypoglycemia have increased uptake in all pancreatic regions. Carbidopa pretreatment lowers pancreatic F-FDOPA uptake in the nonaffected pancreas and may therefore mask disease activity in post-gastric bypass hypoglycemia.
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28
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Toda N, Ihara K, Kojima-Ishii K, Ochiai M, Ohkubo K, Kawamoto Y, Kohno Y, Kumasaka S, Kawase A, Ueno Y, Futatani T, Miyazawa T, Nagaoki Y, Nakata S, Misaki M, Arai H, Kawai M, Sato M, Yada Y, Takahashi N, Komatsu A, Maki K, Watabe S, Sumida Y, Kuwashima M, Mizumoto H, Sato K, Hara T. Hyperinsulinemic hypoglycemia in Beckwith-Wiedemann, Sotos, and Kabuki syndromes: A nationwide survey in Japan. Am J Med Genet A 2016; 173:360-367. [PMID: 28102591 DOI: 10.1002/ajmg.a.38011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Accepted: 09/21/2016] [Indexed: 11/06/2022]
Abstract
Beckwith-Wiedemann syndrome (BWS) is a congenital overgrowth syndrome that is occasionally associated with hyperinsulinemic hypoglycemia (HH) in the neonatal period. Sotos syndrome (SS) and Kabuki syndrome (KS) are other malformation syndromes that may be complicated with HH, however, the detailed clinical characteristics of HH accompanied with these syndromes remain unclear. We herein conducted a nationwide questionnaire survey in Japan. We sent a primary questionnaire concerning the clinical experience for these syndromes to 347 perinatal care institutions. As a result, 222 departments or hospitals returned the questionnaires and the total numbers of BWS, SS, and KS patients were 113, 88, and 51, respectively. We sent a secondary questionnaire to 31 institutions where patients with these syndromes presented with HH during infancy. The secondary questionnaires were returned from the institutions and the numbers of patients were 16 for BWS, 9 for SS, and 3 for KS, respectively. Then, we compared the clinical characteristics of infants suffering from transient HH with and without these dysmorphic syndromes. As a result, BWS, SS, and KS patients showed significantly larger body size, lower Apgar scores, higher insulin levels at HH, and shorter durations of HH than non-dysmorphic infants with transient HH. We propose that a careful observation for the signs of HH, even if not specific to the syndromes, is important for the diagnosis of patients with BWS, SS, and KS in the postnatal period. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Naoko Toda
- Department of Pediatrics, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Kenji Ihara
- Department of Pediatrics, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan.,Faculty of Medicine, Department of Pediatrics, Oita University, Oita, Japan
| | - Kanako Kojima-Ishii
- Department of Pediatrics, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Masayuki Ochiai
- Department of Pediatrics, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Kazuhiro Ohkubo
- Department of Pediatrics, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
| | - Yutaka Kawamoto
- Department of Neonatology, Kawasaki Medical School Hospital, Okayama, Japan
| | - Yoshinori Kohno
- Department of Neonatology, Gifu Prefectural General Medical Center, Gifu, Japan
| | - Sakae Kumasaka
- Department of Neonatology, Japanese Red Cross Katsushika Maternity Hospital, Tokyo, Japan
| | - Akihiko Kawase
- Department of Neonatology, Kumamoto City Hospital, Kumamoto, Japan
| | - Yasuhisa Ueno
- Department of Neonatology, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Takeshi Futatani
- Department of Pediatrics, Toyama Prefectural Central Hospital, Toyama, Japan
| | - Tokuo Miyazawa
- Department of Pediatrics, Showa University School of Medicine, Tokyo, Japan
| | - Yuko Nagaoki
- Department of Pediatrics, St Luke's International Hospital, Tokyo, Japan
| | - Setsuko Nakata
- Department of Pediatrics, Iida Municipal Hospital, Iida, Japan
| | - Maiko Misaki
- Department of Pediatrics, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroko Arai
- Department of Neonatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Kawai
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Maki Sato
- Department of Pediatrics, Fukushima Medical University, Fukushima, Japan
| | - Yukari Yada
- Department of Pediatrics, Jichi Medical University, Shimotsuke, Japan
| | - Nobuhiro Takahashi
- Department of Pediatrics, Tenshi Hospital, Social Medical Corporation BOKOI, Sapporo, Japan
| | - Atsushi Komatsu
- Department of Obstetrics and Gynecology, The University of Tokyo Hospital, Tokyo, Japan
| | - Kanemasa Maki
- Department of Pediatrics, Yokkaichi Municipal Hospital, Yokkaichi, Japan
| | - Shinichi Watabe
- Department of Neonatal Intensive Care, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yutaka Sumida
- Department of Pediatrics, Rinku General Medical Center, Izumisano, Japan
| | - Makoto Kuwashima
- Department of Pediatrics, Kiryu Kosei General Hospital, Kiryu, Japan
| | - Hiroshi Mizumoto
- Department of Pediatrics, Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Kazuo Sato
- Department of Pediatrics, National Kyushu Medical Center, Fukuoka, Japan
| | - Toshiro Hara
- Department of Pediatrics, Graduate School of Medical Science, Kyushu University, Fukuoka, Japan
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Martínez R, Fernández-Ramos C, Vela A, Velayos T, Aguayo A, Urrutia I, Rica I, Castaño L. Clinical and genetic characterization of congenital hyperinsulinism in Spain. Eur J Endocrinol 2016; 174:717-26. [PMID: 27188453 DOI: 10.1530/eje-16-0027] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/07/2016] [Indexed: 12/30/2022]
Abstract
CONTEXT Congenital hyperinsulinism (CHI) is a clinically and genetically heterogeneous disease characterized by severe hypoglycemia caused by inappropriate insulin secretion by pancreatic β-cells. OBJECTIVE To characterize clinically and genetically CHI patients in Spain. DESIGN AND METHODS We included 50 patients with CHI from Spain. Clinical information was provided by the referring clinicians. Mutational analysis was carried out for KCNJ11, ABCC8, and GCK genes. The GLUD1, HNF4A, HNF1A, UCP2, and HADH genes were sequenced depending on the clinical phenotype. RESULTS We identified the genetic etiology in 28 of the 50 CHI patients tested: 21 had a mutation in KATP channel genes (42%), three in GLUD1 (6%), and four in GCK (8%). Most mutations were found in ABCC8 (20/50). Half of these patients (10/20) were homozygous or compound heterozygous, with nine being unresponsive to diazoxide treatment. The other half had heterozygous mutations in ABCC8, six of them being unresponsive to diazoxide treatment and four being responsive to diazoxide treatment. We identified 22 different mutations in the KATP channel genes, of which ten were novel. Notably, patients with ABCC8 mutations were diagnosed earlier, with lower blood glucose levels and required higher doses of diazoxide than those without a genetic diagnosis. CONCLUSIONS Genetic analysis revealed mutations in 56% of the CHI patients. ABCC8 mutations are the most frequent cause of CHI in Spain. We found ten novel mutations in the KATP channel genes. The genetic diagnosis is more likely to be achieved in patients with onset within the first week of life and in those who fail to respond to diazoxide treatment.
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Affiliation(s)
- R Martínez
- Endocrinology and Diabetes Research GroupBioCruces Health Research Institute, Cruces University Hospital, CIBERDEM, CIBERER, UPV-EHU, Barakaldo, Spain
| | - C Fernández-Ramos
- Pediatric Endocrinology SectionBasurto University Hospital, BioCruces Health Research Institute, UPV/EHU, Bilbao, Spain
| | - A Vela
- Pediatric Endocrinology SectionCruces University Hospital, BioCruces Health Research Institute, CIBERDEM, CIBERER, UPV/EHU, Barakaldo, Spain
| | - T Velayos
- Endocrinology and Diabetes Research GroupBioCruces Health Research Institute, Cruces University Hospital, CIBERDEM, CIBERER, UPV-EHU, Barakaldo, Spain
| | - A Aguayo
- Endocrinology and Diabetes Research GroupBioCruces Health Research Institute, Cruces University Hospital, CIBERDEM, CIBERER, UPV-EHU, Barakaldo, Spain
| | - I Urrutia
- Endocrinology and Diabetes Research GroupBioCruces Health Research Institute, Cruces University Hospital, CIBERDEM, CIBERER, UPV-EHU, Barakaldo, Spain
| | - I Rica
- Pediatric Endocrinology SectionCruces University Hospital, BioCruces Health Research Institute, CIBERDEM, CIBERER, UPV/EHU, Barakaldo, Spain
| | - L Castaño
- Endocrinology and Diabetes Research GroupBioCruces Health Research Institute, Cruces University Hospital, CIBERDEM, CIBERER, UPV-EHU, Barakaldo, Spain
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30
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Tricarico D, Selvaggi M, Passantino G, De Palo P, Dario C, Centoducati P, Tateo A, Curci A, Maqoud F, Mele A, Camerino GM, Liantonio A, Imbrici P, Zizzo N. ATP Sensitive Potassium Channels in the Skeletal Muscle Function: Involvement of the KCNJ11(Kir6.2) Gene in the Determination of Mechanical Warner Bratzer Shear Force. Front Physiol 2016; 7:167. [PMID: 27242541 PMCID: PMC4862255 DOI: 10.3389/fphys.2016.00167] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 04/25/2016] [Indexed: 12/25/2022] Open
Abstract
The ATP-sensitive K+-channels (KATP) are distributed in the tissues coupling metabolism with K+ ions efflux. KATP subunits are encoded by KCNJ8 (Kir6.1), KCNJ11 (Kir6.2), ABCC8 (SUR1), and ABCC9 (SUR2) genes, alternative RNA splicing give rise to SUR variants that confer distinct physiological properties on the channel. An high expression/activity of the sarco-KATP channel is observed in various rat fast-twitch muscles, characterized by elevated muscle strength, while a low expression/activity is observed in the slow-twitch muscles characterized by reduced strength and frailty. Down-regulation of the KATP subunits of fast-twitch fibers is found in conditions characterized by weakness and frailty. KCNJ11 gene knockout mice have reduced glycogen, lean phenotype, lower body fat, and weakness. KATP channel is also a sensor of muscle atrophy. The KCNJ11 gene is located on BTA15, close to a QTL for meat tenderness, it has also a role in glycogen storage, a key mechanism of the postmortem transformation of muscle into meat. The role of KCNJ11 gene in muscle function may underlie an effect of KCNJ11 genotypes on meat tenderness, as recently reported. The fiber phenotype and genotype are important in livestock production science. Quantitative traits including meat production and quality are influenced both by environment and genes. Molecular markers can play an important role in the genetic improvement of animals through breeding strategies. Many factors influence the muscle Warner-Bratzler shear force including breed, age, feeding, the biochemical, and functional parameters. The role of KCNJ11gene and related genes on muscle tenderness will be discussed in the present review.
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Affiliation(s)
- Domenico Tricarico
- Department of Pharmacy-Drug Science, University of Bari Aldo Moro Bari, Italy
| | - Maria Selvaggi
- Section of Veterinary Science and Animal Production, Department of Emergency and Organ Transplantation (DETO), University of Bari Aldo Moro Valenzano, Italy
| | | | - Pasquale De Palo
- Department of Veterinary Medicine, University of Bari Aldo Moro Bari, Italy
| | - Cataldo Dario
- Section of Veterinary Science and Animal Production, Department of Emergency and Organ Transplantation (DETO), University of Bari Aldo Moro Valenzano, Italy
| | | | - Alessandra Tateo
- Department of Veterinary Medicine, University of Bari Aldo Moro Bari, Italy
| | - Angela Curci
- Department of Pharmacy-Drug Science, University of Bari Aldo Moro Bari, Italy
| | - Fatima Maqoud
- Department of Pharmacy-Drug Science, University of Bari Aldo MoroBari, Italy; Faculty of Science, Chouaib Doukkali UniversityEl Jadida, Morocco
| | - Antonietta Mele
- Department of Pharmacy-Drug Science, University of Bari Aldo Moro Bari, Italy
| | - Giulia M Camerino
- Department of Pharmacy-Drug Science, University of Bari Aldo Moro Bari, Italy
| | - Antonella Liantonio
- Department of Pharmacy-Drug Science, University of Bari Aldo Moro Bari, Italy
| | - Paola Imbrici
- Department of Pharmacy-Drug Science, University of Bari Aldo Moro Bari, Italy
| | - Nicola Zizzo
- Department of Veterinary Medicine, University of Bari Aldo Moro Bari, Italy
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31
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Gong C, Huang S, Su C, Qi Z, Liu F, Wu D, Cao B, Gu Y, Li W, Liang X, Liu M. Congenital hyperinsulinism in Chinese patients: 5-yr treatment outcome of 95 clinical cases with genetic analysis of 55 cases. Pediatr Diabetes 2016; 17:227-34. [PMID: 25639667 DOI: 10.1111/pedi.12254] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/18/2014] [Accepted: 12/19/2014] [Indexed: 12/13/2022] Open
Abstract
AIM The aim of this study is to investigate the clinical features, therapeutic outcomes, and genetic mutations of congenital hyperinsulinism (CHI) in Chinese patients. METHODS The clinical features and therapeutic outcomes of 95 CHI cases were recorded, and genetic analyses were conducted to identify mutations in ABCC8 and KCNJ11 in 55 cases. Direct sequencing was carried out in 25 of the cases with ABCC8 and KCNJ11 mutations. Additionally, 16 samples with no mutations and the remaining 30 samples were sequenced using Ion Torrent platform. RESULTS Clinical misdiagnosis occurred in 36/95 (38%) of the cases. Most (82/95; 84%) of the patients were given diazoxide therapy combined with age-dependent frequent feeding, which was effective in 54/95 (66%) cases. The side effects of diazoxide included sodium and water retention, gastrointestinal reactions, polytrichia, and thrombocytopenia. Five patients were treated with octreotide for 1-4 months, of which 80% (4/5) showed a positive response. Non-surgical therapy was effective in 71/95 (75%) cases. Of the four children who received subtotal pancreatectomy, only one had a good outcome. The remission rate of hypoglycemia was 59% for children over 2-yr-old. The CHI-related gene mutation rate was 38% for potassium channel-related genes. Early onset of CHI and a lower diazoxide response rate were associated with potassium-ATP channel gene mutations. CONCLUSION Age-dependent frequent feeding is an acceptable therapy for CHI. Non-surgical therapy may be highly effective, in part, due to the low rate of potassium channel gene mutations. Surgical outcomes are unreliable without 18F-fluoro-L-DOPA positron emission tomography. Therefore, we do not recommend operation without definitive identification of the pathologic type.
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Affiliation(s)
- Chunxiu Gong
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Shuyue Huang
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Chang Su
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Zhan Qi
- Department of Pediatrics, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Fang Liu
- Institute of Basic Medical Sciences, Peking Union Medical College, Beijing, China
| | - Di Wu
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Bingyan Cao
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Yi Gu
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Wenjin Li
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Xuejun Liang
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
| | - Min Liu
- Department of Pediatric Endocrinology and Genetic Metabolism, Beijing Children's Hospital Affiliated with Capital Medical University, Beijing, China
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32
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Méder Ü, Bokodi G, Balogh L, Körner A, Szabó M, Pruhova S, Szabó AJ. Severe Hyperinsulinemic Hypoglycemia in a Neonate: Response to Sirolimus Therapy. Pediatrics 2015; 136:e1369-72. [PMID: 26504129 DOI: 10.1542/peds.2014-4200] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Hyperinsulinemic hypoglycemia (HH) is one of the most common causes of persistent hypoglycemic episodes in neonates. Current pharmacologic treatment of neonatal HH includes diazoxide and octreotide, whereas for diffuse, unresponsive cases a subtotal pancreatectomy may be the last resort, with questionable efficacy. Here we report a case of congenital diffuse neonatal HH, first suspected when severe hypoglycemia presented with extremely high serum insulin levels immediately after birth. Functional imaging and genetic tests later confirmed the diagnosis. Failure to respond to a sequence of different treatments and to avoid extensive surgery with predictable morbidity prompted us to introduce a recently suggested alternative therapy with sirolimus, a mammalian target of rapamycin inhibitor. Glucose intake could be reduced gradually while euglycemia was maintained, and we were able to achieve exclusively enteral feeding within 6 weeks. Sirolimus was found to be effective and well tolerated, with no major adverse side effects attributable to its administration.
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Affiliation(s)
- Ünőke Méder
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary;
| | - Géza Bokodi
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Lídia Balogh
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Anna Körner
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Miklós Szabó
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Stepanka Pruhova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic; and
| | - Attila J Szabó
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; Pediatrics and Nephrology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
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33
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Carrasco Salas P, Palma Milla C, Lezana Rosales JM, Benito C, Franco Freire S, López Siles J. Hyperinsulinemic hypoglycemia in a patient with an intragenic NSD1 mutation. Am J Med Genet A 2015; 170A:544-546. [PMID: 26487424 DOI: 10.1002/ajmg.a.37440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/03/2015] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Carmen Benito
- Fetal-Maternal Hospital, Carlos Haya Regional University Hospital, Málaga, Spain
| | - Sara Franco Freire
- Fetal-Maternal Hospital, Carlos Haya Regional University Hospital, Málaga, Spain
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34
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Maiorana A, Manganozzi L, Barbetti F, Bernabei S, Gallo G, Cusmai R, Caviglia S, Dionisi-Vici C. Ketogenic diet in a patient with congenital hyperinsulinism: a novel approach to prevent brain damage. Orphanet J Rare Dis 2015; 10:120. [PMID: 26399329 PMCID: PMC4581011 DOI: 10.1186/s13023-015-0342-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/10/2015] [Indexed: 11/23/2022] Open
Abstract
Background Congenital hyperinsulinism (CHI) is the most frequent cause of hypoglycemia in children. In addition to increased peripheral glucose utilization, dysregulated insulin secretion induces profound hypoglycemia and neuroglycopenia by inhibiting glycogenolysis, gluconeogenesis and lipolysis. This results in the shortage of all cerebral energy substrates (glucose, lactate and ketones), and can lead to severe neurological sequelae. Patients with CHI unresponsive to medical treatment can be subjected to near-total pancreatectomy with increased risk of secondary diabetes. Ketogenic diet (KD), by reproducing a fasting-like condition in which body fuel mainly derives from beta-oxidation, is intended to provide alternative cerebral substrates such ketone bodies. We took advantage of known protective effect of KD on neuronal damage associated with GLUT1 deficiency, a disorder of impaired glucose transport across the blood-brain barrier, and administered KD in a patient with drug-unresponsive CHI, with the aim of providing to neurons an energy source alternative to glucose. Methods A child with drug-resistant, long-standing CHI caused by a spontaneous GCK activating mutation (p.Val455Met) suffered from epilepsy and showed neurodevelopmental abnormalities. After attempting various therapeutic regimes without success, near-total pancreatectomy was suggested to parents, who asked for other options. Therefore, we proposed KD in combination with insulin-suppressing drugs. Results We administered KD for 2 years. Soon after the first six months, the patient was free of epileptic crises, presented normalization of EEG, and showed a marked recover in psychological development and quality of life. Conclusions KD could represent an effective treatment to support brain function in selected cases of CHI.
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Affiliation(s)
- Arianna Maiorana
- Metabolic Unit, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Lucilla Manganozzi
- Metabolic Unit, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Fabrizio Barbetti
- Department of Experimental Medicine, University of Tor Vergata and Bambino Gesù Children's Hospital, Rome, Italy.
| | - Silvia Bernabei
- Clinical Nutrition, Gastroenterology Department, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Giorgia Gallo
- Metabolic Unit, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Raffaella Cusmai
- Neurology, Neuroscience Department, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Stefania Caviglia
- Psychology Unit, Neuroscience Department, Bambino Gesù Children's Hospital, Rome, Italy.
| | - Carlo Dionisi-Vici
- Metabolic Unit, Department of Pediatric Medicine, Bambino Gesù Children's Hospital, piazza S. Onofrio 4, 00165, Rome, Italy.
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Nakamura Y, Takagi M, Yoshihashi H, Miura M, Narumi S, Hasegawa T, Miyake Y, Hasegawa Y. A case with neonatal hyperinsulinemic hypoglycemia: It is a characteristic complication of sotos syndrome. Am J Med Genet A 2015; 167A:1171-4. [DOI: 10.1002/ajmg.a.36996] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2014] [Accepted: 01/11/2015] [Indexed: 11/05/2022]
Affiliation(s)
| | - Masaki Takagi
- Division of Endocrinology and Metabolism; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Hiroshi Yoshihashi
- Division of Medical Genetics; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Masaru Miura
- Division of Cardiology; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
| | - Satoshi Narumi
- Department of Pediatrics; Keio University School of Medicine; Tokyo Japan
| | - Tomonobu Hasegawa
- Department of Pediatrics; Keio University School of Medicine; Tokyo Japan
| | | | - Yukihiro Hasegawa
- Division of Genetic Research; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
- Division of Endocrinology and Metabolism; Tokyo Metropolitan Children's Medical Center; Tokyo Japan
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Senniappan S, Ismail D, Shipster C, Beesley C, Hussain K. The heterogeneity of hyperinsulinaemic hypoglycaemia in 19 patients with Beckwith-Wiedemann syndrome due to KvDMR1 hypomethylation. J Pediatr Endocrinol Metab 2015; 28:83-6. [PMID: 24468603 DOI: 10.1515/jpem-2013-0390] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 11/19/2013] [Indexed: 11/15/2022]
Abstract
Beckwith-Wiedemann syndrome (BWS) is an overgrowth syndrome caused by multiple epigenetic and genetic changes affecting imprinted genes on chromosome 11p15.5. Hypomethylation of KvDMR1 on the maternal allele is the most common genetic cause, and hyperinsulinaemic hypoglycaemia (HH) is the most common biochemical abnormality. We evaluated the correlation between severity of HH and degree of hypomethylation in BWS. Out of the 19 patients with BWS due to KvDMR1 hypomethylation, 10 patients had no HH, 5 had mild transient HH that resolved spontaneously, and 4 required diazoxide therapy for up to 6 months. There was no correlation between the degree of KvDMR1 hypomethylation and severity of HH in the 6 patients studied. All patients also showed marked clinical heterogeneity with respect to the features of BWS. In patients with BWS due to hypomethylation of KvDMR1, the clinical presentation of HH is quite heterogeneous with no correlation with the degree of KvDMR1 hypomethylation.
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Mohnike K, Wieland I, Barthlen W, Vogelgesang S, Empting S, Mohnike W, Meissner T, Zenker M. Clinical and genetic evaluation of patients with KATP channel mutations from the German registry for congenital hyperinsulinism. Horm Res Paediatr 2014; 81:156-68. [PMID: 24401662 DOI: 10.1159/000356905] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 10/03/2013] [Indexed: 11/19/2022] Open
Abstract
Congenital hyperinsulinism (CHI) causes hypoglycemia due to irregular insulin secretion. In infants, a rapid diagnosis and appropriate management to avoid severe hypoglycemia is mandatory. CHI is a heterogeneous condition at the clinical and genetic level, and disease-causing genes have been identified in about half of the patients. The majority of mutations have been identified in the ABCC8 and KCNJ11 genes encoding subunits of the KATP channel responsible for two distinct histological forms. The diffuse form is caused by autosomal recessive or dominant inherited mutations, whereas the focal form is caused by a paternally transmitted recessive mutation and a second somatic event. We report on an unselected cohort of 136 unrelated patients from the German CHI registry. Mutations in either the ABCC8 or KCNJ11 gene were identified in 61 of these patients (45%). In total, 64 different mutations including 38 novel ones were detected in this cohort. We observed biparental (recessive) inheritance in 34% of mutation-positive patients, dominant inheritance in 11% and paternal transmission of a mutation associated with a focal CHI type in 38%. In addition, we observed inheritance patterns that do not exactly follow the classical recessive or dominant mode, further adding to the genetic complexity of this disease.
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Affiliation(s)
- Klaus Mohnike
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
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38
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Kühnen P, Matthae R, Arya V, Hauptmann K, Rothe K, Wächter S, Singer M, Mohnike W, Eberhard T, Raile K, Lauffer LM, Iakoubov R, Hussain K, Blankenstein O. Occurrence of giant focal forms of congenital hyperinsulinism with incorrect visualization by (18) F DOPA-PET/CT scanning. Clin Endocrinol (Oxf) 2014; 81:847-54. [PMID: 24750227 DOI: 10.1111/cen.12473] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Revised: 01/09/2014] [Accepted: 04/14/2014] [Indexed: 11/29/2022]
Abstract
CONTEXT Congenital hyperinsulinism (CHI) is a rare disease characterized by severe hypoglycaemic episodes due to pathologically increased insulin secretion from the pancreatic beta cells. When untreated, CHI might result in irreversible brain damage and death. Currently, two major subtypes of CHI are known: a focal form, associated with local distribution of affected beta cells and a nonfocal form, affecting every single beta cell. The identification of focal forms is important, as the patients can be cured by limited surgery. (18) F DOPA-PET/CT is an established non-invasive approach to differentiate focal from nonfocal CHI. OBJECTIVE The purpose of this study was to identify possible limitations of (18) F DOPA-PET/CT scan in patients with focal forms nonfocal CHI. DESIGN A retrospective chart review of 32 patients (from 2008 through 2013) who underwent (18) F DOPA-PET/CT and partial pancreatectomy for focal CHI at the reference centres in Berlin, Germany and London, UK. RESULTS In most cases (n = 29, 90·7%), (18) F DOPA-PET/CT was sufficient to localize the complete focal lesion. However, in some patients (n = 3, 9·3%), (18) F DOPA-PET/CT wrongly visualized only a small portion of the focal lesion. In this group of patients, a so-called 'giant focus' was detected in histopathological analysis during the surgery. CONCLUSIONS Our data show that in most patients with focal CHI (18) F DOPA-PET/CT correctly predicts the size and anatomical localisation of the lesion. However, in those patients with a 'giant focal' lesion (18) F DOPA-PET/CT is unreliable for correct identification of 'giant focus' cases.
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Affiliation(s)
- Peter Kühnen
- Institut für experimentelle pädiatrische Endokrinologie, Charité Universitätsmedizin, Berlin, Germany
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Maiorana A, Barbetti F, Boiani A, Rufini V, Pizzoferro M, Francalanci P, Faletra F, Nichols CG, Grimaldi C, de Ville de Goyet J, Rahier J, Henquin JC, Dionisi-Vici C. Focal congenital hyperinsulinism managed by medical treatment: a diagnostic algorithm based on molecular genetic screening. Clin Endocrinol (Oxf) 2014; 81:679-88. [PMID: 24383515 DOI: 10.1111/cen.12400] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/24/2013] [Accepted: 12/31/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Congenital hyperinsulinism (CHI) requires rapid diagnosis and treatment to avoid irreversible neurological sequelae due to hypoglycaemia. Aetiological diagnosis is instrumental in directing the appropriate therapy. Current diagnostic algorithms provide a complete set of diagnostic tools including (i) biochemical assays, (ii) genetic facility and (iii) state-of-the-art imaging. They consider the response to a therapeutic diazoxide trial an early, crucial step before proceeding (or not) to specific genetic testing and eventually imaging, aimed at distinguishing diffuse vs focal CHI. However, interpretation of the diazoxide test is not trivial and can vary between research groups, which may lead to inappropriate decisions. Objective of this report is proposing a new algorithm in which early genetic screening, rather than diazoxide trial, dictates subsequent clinical decisions. PATIENTS, METHODS AND RESULTS Two CHI patients weaned from parenteral glucose infusion and glucagon after starting diazoxide. No hypoglycaemia was registered during a 72-h continuous glucose monitoring (CGMS), or hypoglycaemic episodes were present for no longer than 3% of 72-h. Normoglycaemia was obtained by low-medium dose diazoxide combined with frequent carbohydrate feeds for several years. We identified monoallelic, paternally inherited mutations in KATP channel genes, and (18) F-DOPA PET-CT revealed a focal lesion that was surgically resected, resulting in complete remission of hypoglycaemia. CONCLUSIONS Although rare, some patients with focal lesions may be responsive to diazoxide. As a consequence, we propose an algorithm that is not based on a 'formal' diazoxide response but on genetic testing, in which patients carrying paternally inherited ABCC8 or KCNJ11 mutations should always be subjected to (18) F-DOPA PET-CT.
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Affiliation(s)
- Arianna Maiorana
- Department of Pediatrics, Metabolic Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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40
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Petraitienė I, Barauskas G, Gulbinas A, Malcius D, Hussain K, Verkauskas G, Verkauskienė R. Congenital hyperinsulinism. MEDICINA-LITHUANIA 2014; 50:190-5. [PMID: 25323548 DOI: 10.1016/j.medici.2014.08.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 06/03/2014] [Indexed: 11/27/2022]
Abstract
Hyperinsulinism is the most common cause of hypoglycemia in infants. In many cases conservative treatment is not effective and surgical intervention is required. Differentiation between diffuse and focal forms and localization of focal lesions are the most important issues in preoperative management. We present a case of persistent infancy hyperinsulinism. Clinical presentation, conservative treatment modalities, diagnostic possibilities of focal and diffuse forms, and surgical treatment, which led to total recovery, are discussed.
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Affiliation(s)
- Indrė Petraitienė
- Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Giedrius Barauskas
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Antanas Gulbinas
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Institute for Digestive Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Dalius Malcius
- Department of Pediatric Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Khalid Hussain
- Great Ormond Street Hospital for Children NHS Trust and Institute of Child Health, University College London, London, UK
| | - Gilvydas Verkauskas
- Children's Hospital, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania
| | - Rasa Verkauskienė
- Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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41
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Corbin JA, Bhaskar V, Goldfine ID, Issafras H, Bedinger DH, Lau A, Michelson K, Gross LM, Maddux BA, Kuan HF, Tran C, Lao L, Handa M, Watson SR, Narasimha AJ, Zhu S, Levy R, Webster L, Wijesuriya SD, Liu N, Wu X, Chemla-Vogel D, Lee SR, Wong S, Wilcock D, Rubin P, White ML. Inhibition of insulin receptor function by a human, allosteric monoclonal antibody: a potential new approach for the treatment of hyperinsulinemic hypoglycemia. MAbs 2014; 6:262-72. [PMID: 24423625 PMCID: PMC3929448 DOI: 10.4161/mabs.26871] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Novel therapies are needed for the treatment of hypoglycemia resulting from both endogenous and exogenous hyperinsulinema. To provide a potential new treatment option, we identified XMetD, an allosteric monoclonal antibody to the insulin receptor (INSR) that was isolated from a human antibody phage display library. To selectively obtain antibodies directed at allosteric sites, panning of the phage display library was conducted using the insulin-INSR complex. Studies indicated that XMetD bound to the INSR with nanomolar affinity. Addition of insulin reduced the affinity of XMetD to the INSR by 3-fold, and XMetD reduced the affinity of the INSR for insulin 3-fold. In addition to inhibiting INSR binding, XMetD also inhibited insulin-induced INSR signaling by 20- to 100-fold. These signaling functions included INSR autophosphorylation, Akt activation and glucose transport. These data indicated that XMetD was an allosteric antagonist of the INSR because, in addition to inhibiting the INSR via modulation of binding affinity, it also inhibited the INSR via modulation of signaling efficacy. Intraperitoneal injection of XMetD at 10 mg/kg twice weekly into normal mice induced insulin resistance. When sustained-release insulin implants were placed into normal mice, they developed fasting hypoglycemia in the range of 50 mg/dl. This hypoglycemia was reversed by XMetD treatment. These studies demonstrate that allosteric monoclonal antibodies, such as XMetD, can antagonize INSR signaling both in vitro and in vivo. They also suggest that this class of allosteric monoclonal antibodies has the potential to treat hyperinsulinemic hypoglycemia resulting from conditions such as insulinoma, congenital hyperinsulinism and insulin overdose.
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Affiliation(s)
- John A Corbin
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Vinay Bhaskar
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Ira D Goldfine
- Department of Medicine; University of California; San Francisco, CA USA
| | | | | | - Angela Lau
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | | | - Lisa M Gross
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Betty A Maddux
- Department of Medicine; University of California; San Francisco, CA USA
| | - Hua F Kuan
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Catarina Tran
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Llewelyn Lao
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Masahisa Handa
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Susan R Watson
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | | | - Shirley Zhu
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Raphael Levy
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Lynn Webster
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | | | - Naichi Liu
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Xiaorong Wu
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | | | - Steve R Lee
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Steve Wong
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Diane Wilcock
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Paul Rubin
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
| | - Mark L White
- Preclinical Research; XOMA Corporation; Berkeley, CA USA
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Zarate YA, Shur N, Robin A, Garnica AD, Quintos JB, Schaefer GB. Persistent congenital hyperinsulinism in two patients with Beckwith-Wiedemann syndrome due to mosaic uniparental disomy 11p. J Pediatr Endocrinol Metab 2014; 27:951-5. [PMID: 24756053 DOI: 10.1515/jpem-2013-0484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/18/2014] [Indexed: 11/15/2022]
Abstract
Congenital hyperinsulinism (CHI) is a rare metabolic disease characterized by inappropriate insulin secretion in the presence of hypoglycemia. We describe the clinical presentation and management of congenital hyperinsulinism and persistent hypoglycemia in two infants. Both patients had an initial clinical diagnosis of Beckwith-Wiedemann syndrome (BWS) but normal methylation analysis for LIT1 and H19 status. Both patients were eventually found to have mosaic uniparental disomy 11p diagnosed by single nucleotide polymorphism (SNP) array in DNA isolated from lymphoblasts and fibroblasts, respectively. We report that patients with mosaic BWS are at increased risk for both transient and refractory hypoglycemia that may need aggressive management with diazoxide, octreotide, high glucose infusion rates, and a frequent feeding regime. Our patient experience supports the case for pursuing further testing in patients with features of BWS with normal methylation studies, karyotype, and SNP arrays on blood. The next logical step is SNP array on skin biopsy to rule out mosaicism.
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43
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Montravers F, Arnoux JB, Ribeiro MJ, Kerrou K, Nataf V, Galmiche L, Aigrain Y, Bellanné-Chantelot C, Saint-Martin C, Ohnona J, Balogova S, Huchet V, Michaud L, Talbot JN, de Lonlay P. Strengths and limitations of using 18fluorine-fluorodihydroxyphenylalanine PET/CT for congenital hyperinsulinism. Expert Rev Endocrinol Metab 2014; 9:477-485. [PMID: 30736210 DOI: 10.1586/17446651.2014.949240] [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] [Indexed: 11/08/2022]
Abstract
18fluorine-fluorodihydroxyphenylalanine (FDOPA) PET/CT is currently the first-line imaging technique to distinguish between focal and diffuse forms of congenital hyperinsulinism (CHI) and to accurately localize focal forms. However, this technique has a number of limitations, mainly the very small size of focal forms or inversely a very large focal form mimicking a diffuse form, and misinterpretation of physiologic uptake masking hot spots or inversely mimicking focal forms. The other limitation is the limited availability of the radiopharmaceutical. FDOPA PET/CT has no recognized competitor to date among the available morphologic and functional imaging techniques. Other potential approaches using specific tracers for positron emission tomography (PET) are discussed, using radiopharmaceuticals specific for β cell mass or targeting somatostatin receptors. These radiopharmaceuticals can be labeled with gallium-68, a PET emitter readily available in PET centers equipped with 68Ge/68Ga generators.
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Affiliation(s)
- Françoise Montravers
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jean-Baptiste Arnoux
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Maria-Joao Ribeiro
- c Service de médecine nucléaire, CHRU, Université François Rabelais, INSERM U930, Tours, France
| | - Khaldoun Kerrou
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Valérie Nataf
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Louise Galmiche
- d Service d'anatomo-pathologie, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Yves Aigrain
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Christine Bellanné-Chantelot
- e Département de génétique, AP-HP Groupe Hospitalier Pitié-Salpétrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Cécile Saint-Martin
- e Département de génétique, AP-HP Groupe Hospitalier Pitié-Salpétrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jessica Ohnona
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Sona Balogova
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
- f Department of nuclear medicine, Comenius University and St. Elisabeth Institute, Bratislava, Slovakia
| | - Virginie Huchet
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Laure Michaud
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jean-Noël Talbot
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Pascale de Lonlay
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
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Dual response of the KATP channels to staurosporine: a novel role of SUR2B, SUR1 and Kir6.2 subunits in the regulation of the atrophy in different skeletal muscle phenotypes. Biochem Pharmacol 2014; 91:266-75. [PMID: 24998494 DOI: 10.1016/j.bcp.2014.06.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 06/26/2014] [Accepted: 06/26/2014] [Indexed: 11/23/2022]
Abstract
We investigated on the role of the genes encoding for the ATP-sensitive K(+)-channel (KATP) subunits (SUR1-2A/B, Kir6.2) in the atrophy induced "in vitro" by staurosporine (STS) in different skeletal muscle phenotypes of mouse. Patch-clamp and gene expression experiments showed that the expression/activity of the sarcolemma KATP channel subunits was higher in the fast-twitch than in the slow-twitch fibers. After 1 to 3h of incubation time, the STS (2.14×10(-6)M) treatment enhanced the expression/activity of the SUR2B, SUR1 and Kir6.2 subunit genes, but not SUR2A, in the slow-twitch muscle fibers, induced the caspase-3-9, Atrogin-1 and Murf-1 gene expression without affecting protein content. After 3 to 6h, the STS-related atrophy markedly down-regulated the SUR2B, SUR1 and Kir6.2 genes reducing the KATP currents and reduced the protein content/muscle weight ratio of the slow-twitch muscle by -36.4±6% (p<0.05). After 6 to 24h, no additional changes of the SUR1-2B and Kir6.2 gene expression and muscle protein were observed. In the fast-twitch muscles, STS mildly affected the atrophic genes and protein content, but potentiated the KATP currents down-regulating the Bnip-3 gene. Diazoxide (250-500×10(-6)M), a SUR1-2B/Kir6.2 channel opener, prevented the protein loss induced by STS in the slow-twitch muscle after 6h showing an EC50 of 1.35×10(-7)M and Emax of 75%, down-regulated the caspase-9 gene and enhanced the KATP currents. The enhanced expression/activity of the SUR2B, SUR1 and Kir6.2 genes are cytoprotective against STS-induced atrophy in the slow-twitch muscle; their reduced expression/activity is associated with proteolysis and atrophy in skeletal muscle.
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Issafras H, Bedinger DH, Corbin JA, Goldfine ID, Bhaskar V, White ML, Rubin P, Scannon PJ. Selective allosteric antibodies to the insulin receptor for the treatment of hyperglycemic and hypoglycemic disorders. J Diabetes Sci Technol 2014; 8:865-73. [PMID: 24876415 PMCID: PMC4764207 DOI: 10.1177/1932296814529886] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Many therapeutic monoclonal antibodies act as antagonists to receptors by targeting and blocking the natural ligand binding site (orthosteric site). In contrast, the use of antibodies to target receptors at allosteric sites (distinct from the orthosteric site) has not been extensively studied. This approach is especially important in metabolic diseases in which endogenous ligand levels are dysregulated. Herein, we review our investigations of 3 categories of human monoclonal antibodies that bind allosterically to the insulin receptor (INSR) and affect its activity: XMetA, XMetS and XMetD. XMetA directly activates the INSR either alone or in combination with insulin. XMetS, in contrast, does not directly activate the INSR but markedly enhances the receptor's ability to bind insulin and potentiate insulin signaling. Both XMetA and XMetS are effective in controlling hyperglycemia in mouse models of diabetes. A third allosteric antibody, XMetD, is an inhibitor of INSR signaling. This antibody reverses insulin-induced hypoglycemia in a mouse model of hyperinsulinemia. These studies indicate, therefore, that allosteric antibodies to INSR can modulate its signaling and correct conditions of glucose dysregulation. These studies also raise the possibility that the use of allosteric antibodies can be expanded to other receptors for the treatment of metabolic disorders.
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Affiliation(s)
| | | | - John A Corbin
- Preclinical Research, XOMA Corporation, Berkeley, CA, USA
| | - Ira D Goldfine
- Preclinical Research, XOMA Corporation, Berkeley, CA, USA Department of Medicine, University of California, San Francisco, USA
| | - Vinay Bhaskar
- Preclinical Research, XOMA Corporation, Berkeley, CA, USA
| | - Mark L White
- Preclinical Research, XOMA Corporation, Berkeley, CA, USA
| | - Paul Rubin
- Preclinical Research, XOMA Corporation, Berkeley, CA, USA
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Yorifuji T. Congenital hyperinsulinism: current status and future perspectives. Ann Pediatr Endocrinol Metab 2014; 19:57-68. [PMID: 25077087 PMCID: PMC4114053 DOI: 10.6065/apem.2014.19.2.57] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 04/14/2014] [Indexed: 11/25/2022] Open
Abstract
The diagnosis and treatment of congenital hyperinsulinism (CHI) have made a remarkable progress over the past 20 years and, currently, it is relatively rare to see patients who are left with severe psychomotor delay. The improvement was made possible by the recent developments in the understanding of the molecular and pathological basis of CHI. Known etiologies include inactivating mutations of the KATP channel genes (ABCC8 and KCNJ11) and HNF4A, HNF1A, HADH, and UCP2 or activating mutations of GLUD1, GCK, and SLC16A1. The understanding of the focal form of KATP channel CHI and its detection by (18)F-fluoro-L-DOPA positron emission tomography have revolutionized the management of CHI, and many patients can be cured without postoperative diabetes mellitus. The incidence of the focal form appears to be higher in Asian countries; therefore, the establishment of treatment systems is even more important in this population. In addition to diazoxide or long-term subcutaneous infusion of octreotide or glucagon, long-acting octreotide or lanreotide have also been used successfully until spontaneous remission. Because of these medications, near-total pancreatectomy is less often performed even for the diazoxide-unresponsive diffuse form of CHI. Other promising medications include pasireotide, small-molecule correctors such as sulfonylurea or carbamazepine, GLP1 receptor antagonists, or mammalian target of rapamycin inhibitors. Unsolved questions in this field include the identification of the remaining genes responsible for CHI, the mechanisms leading to transient CHI, and the mechanisms responsible for the spontaneous remission of CHI. This article reviews recent developments and hypothesis regarding these questions.
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Affiliation(s)
- Tohru Yorifuji
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
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Insulinoma: only in adults?-case reports and literature review. Eur J Pediatr 2014; 173:567-74. [PMID: 23604412 DOI: 10.1007/s00431-013-2005-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 04/10/2013] [Indexed: 10/26/2022]
Abstract
Insulinomas first presenting as refractory seizure disorders are well documented in adulthood but rarely found in children. Only a few cases of childhood insulinoma have been reported so far. We report on two adolescents with hyperinsulinaemic hypoglycaemia, initially misdiagnosed as epilepsy and migraine accompagnée, and compare those to other cases published. Localization of insulinoma was challenging and, in one patient, angiography with selective arterial calcium stimulation and hepatic venous sampling in addition to CT and MRI was necessary. In these patients, long-term recovery was achieved by laparoscopic distal pancreatic resection in one and by conventional enucleation in the pancreatic head in the second patient. In contrast to adults, macrosomy and a decrease in school performance were the main symptoms and, during fasting, impaired cognitive function occurred after a relatively short period and at a higher glucose threshold or lower insulin/glucose ratio, respectively. Neuroglycopenic signs may be attributed to behaviour abnormalities or seizure disorders but in children and adolescents may already be caused by insulinoma. In these cases, timely diagnosis as well as tumour resection ensure long-term cure.
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Mele A, Calzolaro S, Cannone G, Cetrone M, Conte D, Tricarico D. Database search of spontaneous reports and pharmacological investigations on the sulfonylureas and glinides-induced atrophy in skeletal muscle. Pharmacol Res Perspect 2014; 2:e00028. [PMID: 25505577 PMCID: PMC4186404 DOI: 10.1002/prp2.28] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 01/09/2014] [Accepted: 01/11/2014] [Indexed: 12/14/2022] Open
Abstract
The ATP-sensitive K(+) (KATP) channel is an emerging pathway in the skeletal muscle atrophy which is a comorbidity condition in diabetes. The "in vitro" effects of the sulfonylureas and glinides were evaluated on the protein content/muscle weight, fibers viability, mitochondrial succinic dehydrogenases (SDH) activity, and channel currents in oxidative soleus (SOL), glycolitic/oxidative flexor digitorum brevis (FDB), and glycolitic extensor digitorum longus (EDL) muscle fibers of mice using biochemical and cell-counting Kit-8 assay, image analysis, and patch-clamp techniques. The sulfonylureas were: tolbutamide, glibenclamide, and glimepiride; the glinides were: repaglinide and nateglinide. Food and Drug Administration-Adverse Effects Reporting System (FDA-AERS) database searching of atrophy-related signals associated with the use of these drugs in humans has been performed. The drugs after 24 h of incubation time reduced the protein content/muscle weight and fibers viability more effectively in FDB and SOL than in the EDL. The order of efficacy of the drugs in reducing the protein content in FDB was: repaglinide (EC50 = 5.21 × 10(-6)) ≥ glibenclamide(EC50 = 8.84 × 10(-6)) > glimepiride(EC50 = 2.93 × 10(-5)) > tolbutamide(EC50 = 1.07 × 10(-4)) > nateglinide(EC50 = 1.61 × 10(-4)) and it was: repaglinide(7.15 × 10(-5)) ≥ glibenclamide(EC50 = 9.10 × 10(-5)) > nateglinide(EC50 = 1.80 × 10(-4)) ≥ tolbutamide(EC50 = 2.19 × 10(-4)) > glimepiride(EC50=-) in SOL. The drug-induced atrophy can be explained by the KATP channel block and by the enhancement of the mitochondrial SDH activity. In an 8-month period, muscle atrophy was found in 0.27% of the glibenclamide reports in humans and in 0.022% of the other not sulfonylureas and glinides drugs. No reports of atrophy were found for the other sulfonylureas and glinides in the FDA-AERS. Glibenclamide induces atrophy in animal experiments and in human patients. Glimepiride shows less potential for inducing atrophy.
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Affiliation(s)
- Antonietta Mele
- Departments of Pharmacy-Drug Science, University of Bari Bari, Italy
| | - Sara Calzolaro
- Departments of Pharmacy-Drug Science, University of Bari Bari, Italy
| | - Gianluigi Cannone
- Departments of Pharmacy-Drug Science, University of Bari Bari, Italy
| | - Michela Cetrone
- Departments of Pharmacovigilance, University-Hospital Policlinico, Ministry of Health Bari, Italy
| | - Diana Conte
- Departments of Pharmacy-Drug Science, University of Bari Bari, Italy
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Sang Y, Xu Z, Liu M, Yan J, Wu Y, Zhu C, Ni G. Mutational analysis of ABCC8, KCNJ11, GLUD1, HNF4A and GCK genes in 30 Chinese patients with congenital hyperinsulinism. Endocr J 2014; 61:901-10. [PMID: 25008049 DOI: 10.1507/endocrj.ej13-0398] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We conducted a cohort study to elucidate the molecular spectrum of congenital hyperinsulinism (CHI) in Chinese pediatric patients. Thirty Chinese children with CHI were chosen as research subjects, 16 of whom were responsive to diazoxide and 13 of whom were not (1 patient was not given the drug for medical reasons). All exons of the adenosine triphosphate (ATP)-sensitive potassium channel (KATP channel) genes KCNJ11 and ABCC8, the hepatocyte nuclear factor 4 α (HNF4A) gene, and the Glucokinase (GCK) gene as well as exons 6 and 7 and 10-12 of the glutamate dehydrogenase 1 (GLUD1) gene were amplified from genomic DNA and directly sequenced. Mutations were identified in 14 of 30 patients (47%): 3 in GLUD1 (10%) and 11 in the KATP channel genes (37%). Six patients had paternally derived monoallelic KATP channel mutations predictive of the focal CHI form. We found a novel de novo ABCC8 mutation, p. C1000*, a novel paternally inherited ABCC8 mutation, D1505H, and a dominantly inherited ABCC8 mutation, R1217K. The GLUD1 activating mutation R269H was found in 2 patients: 1 de novo and the other paternally inherited. A de novo S445L mutation was found in 1 patient. No significant HNF4A or GCK mutations were found. CHI has complex genetic onset mechanisms. Paternally inherited monoallelic mutations of ABCC8 and KCNJ11 are likely the main causes of KATP-CHI in Chinese patients. Glutamate dehydrogenase-CHI is the second most common cause of CHI, while HNF4A and GCK are rare types of CHI in Chinese patients.
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Affiliation(s)
- Yanmei Sang
- National Key Discipline of Pediatrics (Capital Medical University), Ministry of Education; Department of Endocrinology, genetics and metabolism, Beijing Children's Hospital Affiliated to Capital Medical University, Beijing 100045, China
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Yoshida K, Kawai M, Marumo C, Kanazawa H, Matsukura T, Kusuda S, Yorifuji T, Heike T. High prevalence of severe circulatory complications with diazoxide in premature infants. Neonatology 2014; 105:166-71. [PMID: 24458138 DOI: 10.1159/000356772] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 10/22/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Since diazoxide was approved for clinical use in Japan in 2008, its prescription for the treatment of infants with hyperinsulinemic hypoglycemia (HIH) has rapidly expanded. Concomitantly, reports of complications associated with diazoxide are increasing. OBJECTIVES To clarify the trends and problems associated with the treatment of infants with HIH, we planned a nationwide surveillance in Japan. METHODS Questionnaires were sent to 255 institutions belonging to the Japanese Neonatologist Association inquiring about neonatal cases of HIH from 2009 to 2011. RESULTS One hundred nineteen cases of neonates with transient HIH (THIH) related to perinatal problems and 15 cases with permanent HIH (PHIH; hypoglycemia persisting beyond a year) or genetic HIH were reported. Sixty-four infants (53.8%) with THIH were administered diazoxide, and the administration was completed within 3 months in 46 infants (71.9%). Fourteen of the PHIH or genetic cases were treated with diazoxide and 7 of them (50%) had hypoglycemia persisting beyond a year. Circulatory complications were reported in 15 infants, i.e. 10 with THIH and 5 with PHIH. Multiple regression analysis revealed that a younger gestational age at birth and higher maximum doses of diazoxide were significant risk factors for circulatory complications. CONCLUSIONS Diazoxide is widely prescribed for infants with HIH as a first-line medicine in Japan, but prophylactic diuretics are uncommon. Under these circumstances, a high prevalence of severe circulatory complications in very-low-birth-weight infants was reported.
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Affiliation(s)
- Kayo Yoshida
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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