1
|
Wolfsdorf JI, Derks TGJ, Drachmann D, Shah P, Thornton PS, Weinstein DA. Idiopathic Pathological Ketotic Hypoglycemia: Finding the Needle in a Haystack. Horm Res Paediatr 2024:1-12. [PMID: 38513624 DOI: 10.1159/000538483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/17/2024] [Indexed: 03/23/2024] Open
Abstract
Sick children often have a decreased appetite and experience vomiting and diarrhea; however, hypoglycemia (plasma glucose concentration ≤50 mg/dL or 2.8 mmol/L) is rare. Ketotic hypoglycemia (KH) is the most common cause of hypoglycemia presenting to an Emergency Department in a previously healthy child between 6 months and 6 years of age. Ketosis and hypoglycemia are now well understood to be normal physiologic responses of young children to prolonged fasting.There is now substantial evidence that the term KH describes a variety of conditions including both the lower end of the normal distribution of fasting tolerance in young children as well as numerous rare disorders that impair fasting adaptation. Recent advances in molecular genetic testing have led to the discovery of these rare disorders. Idiopathic pathological KH is a diagnosis of exclusion that describes rare children who have abnormally limited fasting tolerance, experience recurrent episodes of KH, or develop symptoms of hypoglycemia despite elevated ketone levels, and in whom an explanation cannot be found despite extensive investigation. This review provides an approach to distinguishing between physiological KH and pathological KH and includes recommendations for management.
Collapse
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Terry G J Derks
- Section of Metabolic Diseases, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Danielle Drachmann
- Ketotic Hypoglycemia International, Skanderborg, Denmark, Patient-Centered Research, Evidera, London, UK
| | - Pratik Shah
- Paediatric Endocrinology and Diabetes, The Royal London Children's Hospital, Barts Health NHS Trust and Honorary Senior Lecturer, Queen Mary University London, London, UK
| | - Paul S Thornton
- Division of Endocrinology and Diabetes and the Congenital Hyperinsulinism Center, Cook Children's Medical Center and Department of Pediatrics, Burnett School of Medicine, Texas Christian University, Fort Worth, Texas, USA
| | - David A Weinstein
- Department of Pediatrics, University of Connecticut Health Center, Farmington, Connecticut, USA
| |
Collapse
|
2
|
Nguyen K, Boehling J, Tran MN, Cheng T, Rivera A, Collins-Burow BM, Lee SB, Drewry DH, Burow ME. NEK Family Review and Correlations with Patient Survival Outcomes in Various Cancer Types. Cancers (Basel) 2023; 15:2067. [PMID: 37046733 PMCID: PMC10093199 DOI: 10.3390/cancers15072067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/22/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
The Never in Mitosis Gene A (NIMA)-related kinases (NEKs) are a group of serine/threonine kinases that are involved in a wide array of cellular processes including cell cycle regulation, DNA damage repair response (DDR), apoptosis, and microtubule organization. Recent studies have identified the involvement of NEK family members in various diseases such as autoimmune disorders, malignancies, and developmental defects. Despite the existing literature exemplifying the importance of the NEK family of kinases, this family of protein kinases remains understudied. This report seeks to provide a foundation for investigating the role of different NEKs in malignancies. We do this by evaluating the 11 NEK family kinase gene expression associations with patients' overall survival (OS) from various cancers using the Kaplan-Meier Online Tool (KMPlotter) to correlate the relationship between mRNA expression of NEK1-11 in various cancers and patient survival. Furthermore, we use the Catalog of Somatic Mutations in Cancer (COSMIC) database to identify NEK family mutations in cancers of different tissues. Overall, the data suggest that the NEK family has varying associations with patient survival in different cancers with tumor-suppressive and tumor-promoting effects being tissue-dependent.
Collapse
Affiliation(s)
- Khoa Nguyen
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Julia Boehling
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Minh N. Tran
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Thomas Cheng
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - Andrew Rivera
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | | | - Sean B. Lee
- Department of Pathology and Laboratory Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | - David H. Drewry
- UNC Lineberger Comprehensive Cancer Center, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Matthew E. Burow
- Department of Medicine, Tulane University School of Medicine, New Orleans, LA 70112, USA
| |
Collapse
|
3
|
Maiorana A, Lepri FR, Novelli A, Dionisi-Vici C. Hypoglycaemia Metabolic Gene Panel Testing. Front Endocrinol (Lausanne) 2022; 13:826167. [PMID: 35422763 PMCID: PMC9001947 DOI: 10.3389/fendo.2022.826167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/21/2022] [Indexed: 12/31/2022] Open
Abstract
A large number of inborn errors of metabolism present with hypoglycemia. Impairment of glucose homeostasis may arise from different biochemical pathways involving insulin secretion, fatty acid oxidation, ketone bodies formation and degradation, glycogen metabolism, fructose and galactose metabolism, branched chain aminoacids and tyrosine metabolism, mitochondrial function and glycosylation proteins mechanisms. Historically, genetic analysis consisted of highly detailed molecular testing of nominated single genes. However, more recently, the genetic heterogeneity of these conditions imposed to perform extensive molecular testing within a useful timeframe via new generation sequencing technology. Indeed, the establishment of a rapid diagnosis drives specific nutritional and medical therapies. The biochemical and clinical phenotypes are critical to guide the molecular analysis toward those clusters of genes involved in specific pathways, and address data interpretation regarding the finding of possible disease-causing variants at first reported as variants of uncertain significance in known genes or the discovery of new disease genes. Also, the trio's analysis allows genetic counseling for recurrence risk in further pregnancies. Besides, this approach is allowing to expand the phenotypic characterization of a disease when pathogenic variants give raise to unexpected clinical pictures. Multidisciplinary input and collaboration are increasingly key for addressing the analysis and interpreting the significance of the genetic results, allowing rapidly their translation from bench to bedside.
Collapse
Affiliation(s)
- Arianna Maiorana
- Division of Metabolism, Department of Pediatrics Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
- *Correspondence: Arianna Maiorana,
| | - Francesca Romana Lepri
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unity, Ospedale Pediatrico Bambino Gesù, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Antonio Novelli
- Laboratory of Medical Genetics, Translational Cytogenomics Research Unity, Ospedale Pediatrico Bambino Gesù, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Carlo Dionisi-Vici
- Division of Metabolism, Department of Pediatrics Subspecialties, Ospedale Pediatrico Bambino Gesù, IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| |
Collapse
|
4
|
Drachmann D, Carrigg A, Weinstein DA, Petersen JS, Christesen HT. Ketotic hypoglycemia in patients with Down syndrome. JIMD Rep 2021; 62:70-73. [PMID: 34765400 PMCID: PMC8574179 DOI: 10.1002/jmd2.12241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 06/30/2021] [Accepted: 07/02/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Ketotic hypoglycemia (KH) without an identifiable underlying metabolic or hormonal disease is historically named idiopathic KH. The prevalence is unknown, but idiopathic KH is considered the most frequent cause of hypoglycemia beyond the neonatal period. KH in Down syndrome (DS) has not been reported. METHODS We conducted a web-based survey on KH in DS through the non-profit patient organization Ketotic Hypoglycemia International. The responses were evaluated for consistency with KH by two authors. Two DS patient histories with documented KH were shared in more details. RESULTS Survey data on 139 DS patients were obtained. After validation, 10 patients (7.2%) had reported episodes of documented hypoglycemia, ketosis, and/or symptoms compatible with KH beyond the neonatal period. Glucose concentrations ranged 1.2-2.9 mmol/L; betahydroxybutyrate was up to 5.5 mmol/L during hypoglycemia. One girl had trisomy 21 with no response to i.m. glucagon also had a heterozygous Xp22.23 deletion including GYG2, which protein, glycogenin 2, is a substrate for glycogen synthase. Treatment with extended release cornstarch was effective. CONCLUSION This is the first demonstration of a possible high prevalence of KH in DS. Even though this finding needs to be confirmed in other research settings, identification of KH in DS could have a dramatic impact, as simple treatments with cornstarch, protein and frequent meals may prevent KH attacks and, analogous to other conditions with KH, improve growth, stamina and prevent overeating and obesity. GYG2 deletion may contribute to KH in DS, resembling glycogen storage disease type 0.
Collapse
Affiliation(s)
- Danielle Drachmann
- Ketotic Hypoglycemia International (KHI)SkanderborgDenmark
- The Danish Committee for Health EducationCopenhagenDenmark
| | - Austin Carrigg
- Ketotic Hypoglycemia International (KHI)SkanderborgDenmark
| | - David A. Weinstein
- Glycogen Storage Disease Program, Department of PediatricsUniversity of ConnecticutFarmingtonConnecticutUSA
| | | | - Henrik Thybo Christesen
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
- Hans Christian Andersen Children's Hospital and Steno Diabetes Centre OdenseOdense University HospitalOdenseDenmark
| |
Collapse
|
5
|
Benner A, Alhaidan Y, Lines MA, Brusgaard K, De Leon DD, Sparkes R, Frederiksen AL, Christesen HT. PHKA2 variants expand the phenotype of phosphorylase B kinase deficiency to include patients with ketotic hypoglycemia only. Am J Med Genet A 2021; 185:2959-2975. [PMID: 34117828 PMCID: PMC8518678 DOI: 10.1002/ajmg.a.62383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 05/11/2021] [Accepted: 05/23/2021] [Indexed: 12/05/2022]
Abstract
Idiopathic ketotic hypoglycemia (IKH) is a diagnosis of exclusion with glycogen storage diseases (GSDs) as a differential diagnosis. GSD IXa presents with ketotic hypoglycemia (KH), hepatomegaly, and growth retardation due to PHKA2 variants. In our multicenter study, 12 children from eight families were diagnosed or suspected of IKH. Whole‐exome sequencing or targeted next‐generation sequencing panels were performed. We identified two known and three novel (likely) pathogenic PHKA2 variants, such as p.(Pro869Arg), p.(Pro498Leu), p.(Arg2Gly), p.(Arg860Trp), and p.(Val135Leu), respectively. Erythrocyte phosphorylase kinase activity in three patients with the novel variants p.(Arg2Gly) and p.(Arg860Trp) were 15%–20% of mean normal. One patient had short stature and intermittent mildly elevated aspartate aminotransferase, but no hepatomegaly. Family testing identified two asymptomatic children and 18 adult family members with one of the PHKA2 variants, of which 10 had KH symptoms in childhood and 8 had mild symptoms in adulthood. Our study expands the classical GSD IXa phenotype of PHKA2 missense variants to a continuum from seemingly asymptomatic carriers, over KH‐only with phosphorylase B kinase deficiency, to more or less complete classical GSD IXa. In contrast to typical IKH, which is confined to young children, KH may persist into adulthood in the KH‐only phenotype of PHKA2.
Collapse
Affiliation(s)
- Anne Benner
- 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
| | - Yazeid Alhaidan
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Clinical Genetics, Odense University Hospital, Odense, Denmark.,Department of Medical Genomics Research, King Abdullah international medical research center, NGHA, Riyadh, Saudi Arabia
| | - Matthew A Lines
- Department of Medical Genetics, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Klaus Brusgaard
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Diva D De Leon
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rebecca Sparkes
- Department of Medical Genetics, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Anja L Frederiksen
- Department of Clinical Genetics, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University Hospital, Aalborg, 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
| |
Collapse
|
6
|
Drachmann D, Hoffmann E, Carrigg A, Davis-Yates B, Weaver V, Thornton P, Weinstein DA, Petersen JS, Shah P, Christesen HT. Towards enhanced understanding of idiopathic ketotic hypoglycemia: a literature review and introduction of the patient organization, Ketotic Hypoglycemia International. Orphanet J Rare Dis 2021; 16:173. [PMID: 33849624 PMCID: PMC8045369 DOI: 10.1186/s13023-021-01797-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic Ketotic hypoglycemia (IKH) is a diagnosis of exclusion. Although considered as the most frequent cause of hypoglycemia in childhood, little progress has been made to advance the understanding of IKH since the medical term was coined in 1964. We aimed to review the literature on ketotic hypoglycemia (KH) and introduce a novel patient organization, Ketotic Hypoglycemia International (KHI). RESULTS IKH may be diagnosed after the exclusion of various metabolic and hormonal diseases with KH. Although often mild and self-limiting, more severe and long-lasting IKH occurs. We therefore divide IKH in physiological KH and pathological KH, the latter defined as recurrent symptomatic, or occasionally symptomatic, episodes with beta-hydroxybutyrate ≥ 1.0 mmol/L and blood glucose < 70 mg/dL (3.9 mol/L), in the absence of prolonged fasting, acute infections and chronic diseases known to cause KH. Pathological KH may represent undiscovered diseases, e.g. glycogen storage disease IXa, Silver-Russel syndrome, and ketone transporter defects, or suggested novel disease entities identified by exome sequencing. The management of KH aims to prevent hypoglycemia, fatty acid oxidation and protein deficiency by supplying adequate amounts of carbohydrates and protein, including nutritional therapy, uncooked cornstarch, and sometimes continuous tube feeding by night. Still, intravenous dextrose may be needed in acute KH episodes. Failure to acknowledge that IKH can be more than normal variation may lead to under-treatment. KHI is a non-profit, patient-centric, global organization established in 2020. The organization was created by adult IKH patients, patient family members, and volunteers. The mission of KHI is to enhance the understanding of IKH while advocating for patients, their families and the continued research into KH. CONCLUSION IKH is a heterogeneous disorder including physiological KH and pathological KH. IKH may represent missed diagnoses or novel disease entities, but shares common management principles to prevent fatty acid oxygenation. KHI, a novel patient organization, aims to enhance the understanding of IKH by supporting IKH families and research into IKH.
Collapse
Affiliation(s)
| | - Erica Hoffmann
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | - Austin Carrigg
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | - Beccie Davis-Yates
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark.,School of Social Science, Nottingham Institute of Education, Nottingham, UK
| | - Valerie Weaver
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | | | - David A Weinstein
- Glycogen Storage Disease Program, University of Connecticut, Farmington, CT, USA
| | | | - Pratik Shah
- Endocrinology Department, The Royal London Children's Hospital, Barts Health NHS Trust and Queen Mary University London, London, UK
| | - Henrik Thybo Christesen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Hans Christian Andersen Children's Hospital and Steno Diabetes Centre Odense, Odense University Hospital, JB Windsloews Vej 4, 5000, Odense C, Denmark.
| |
Collapse
|
7
|
Alhaidan Y, Christesen HT, Lundberg E, Balwi MAA, Brusgaard K. CRISPR/Cas9 ADCY7 Knockout Stimulates the Insulin Secretion Pathway Leading to Excessive Insulin Secretion. Front Endocrinol (Lausanne) 2021; 12:657873. [PMID: 34177802 PMCID: PMC8231291 DOI: 10.3389/fendo.2021.657873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022] Open
Abstract
AIM Despite the enormous efforts to understand Congenital hyperinsulinism (CHI), up to 50% of the patients are genetically unexplained. We aimed to functionally characterize a novel candidate gene in CHI. PATIENT A 4-month-old boy presented severe hyperinsulinemic hypoglycemia. A routine CHI genetic panel was negative. METHODS A trio-based whole-exome sequencing (WES) was performed. Gene knockout in the RIN-m cell line was established by CRISPR/Cas9. Gene expression was performed using real-time PCR. RESULTS Hyperinsulinemic hypoglycemia with diffuse beta-cell involvement was demonstrated in the patient, who was diazoxide-responsive. By WES, compound heterozygous variants were identified in the adenylyl cyclase 7, ADCY7 gene p.(Asp439Glu) and p.(Gly1045Arg). ADCY7 is calcium-sensitive, expressed in beta-cells and converts ATP to cAMP. The variants located in the cytoplasmic domains C1 and C2 in a highly conserved and functional amino acid region. RIN-m(-/-Adcy7) cells showed a significant increase in insulin secretion reaching 54% at low, and 49% at high glucose concentrations, compared to wild-type. In genetic expression analysis Adcy7 loss of function led to a 34.1-fold to 362.8-fold increase in mRNA levels of the insulin regulator genes Ins1 and Ins2 (p ≤ 0.0002), as well as increased glucose uptake and sensing indicated by higher mRNA levels of Scl2a2 and Gck via upregulation of Pdx1, and Foxa2 leading to the activation of the glucose stimulated-insulin secretion (GSIS) pathway. CONCLUSION This study identified a novel candidate gene, ADCY7, to cause CHI via activation of the GSIS pathway.
Collapse
Affiliation(s)
- Yazeid Alhaidan
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Medical Genomics Research, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- *Correspondence: Yazeid Alhaidan,
| | - Henrik Thybo Christesen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Odense Pancreas Center, Odense, Denmark
| | - Elena Lundberg
- Institute of Clinical Science, Pediatrics, Umea University, Umeå, Sweden
| | - Mohammed A. Al Balwi
- Department of Medical Genomics Research, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, NGHA, Riyadh, Saudi Arabia
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Near East University, Nicosia, Cyprus
| |
Collapse
|