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Larsen AR, Brusgaard K, Christesen HT, Detlefsen S. Genotype-histotype-phenotype correlations in hyperinsulinemic hypoglycemia. Histol Histopathol 2024; 39:817-844. [PMID: 38305063 DOI: 10.14670/hh-18-709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Hyperinsulinemic hypoglycemia (HH) of pancreatic origin includes congenital hyperinsulinism (CHI), insulinoma, insulinomatosis, and adult-onset non-insulinoma persistent hyperinsulinemic hypoglycemia syndrome (NI-PHHS). In this review, we describe the genotype-histotype-phenotype correlations in HH and their therapeutic implications. CHI can occur from birth or later on in life. Histologically, diffuse CHI shows diffuse beta cell hypertrophy with a few giant nuclei per islet of Langerhans, most frequently caused by loss-of-function mutations in ABCC8 or KCNJ11. Focal CHI is histologically characterized by focal adenomatous hyperplasia consisting of confluent hyperplastic islets, caused by a paternal ABCC8/KCNJ11 mutation combined with paternal uniparental disomy of 11p15. CHI in Beckwith-Wiedemann syndrome is caused by mosaic changes in the imprinting region 11p15.4-11p15.5, leading to segmental or diffuse overgrowth of endocrine tissue in the pancreas. Morphological mosaicism of pancreatic islets is characterized by occurence of hyperplastic (type 1) islets in one or a few lobules and small (type 2) islets in the entire pancreas. Other rare genetic causes of CHI show less characteristic or unspecific histology. HH with a predominant adult onset includes insulinomas, which are pancreatic insulin-producing endocrine neoplasms, in some cases with metastatic potential. Insulinomas occur sporadically or as part of multiple endocrine neoplasia type 1 due to MEN1 mutations. MAFA mutations may histologically lead to insulinomatosis with insulin-producing neuroendocrine microadenomas or neuroendocrine neoplasms. NI-PHHS is mainly seen in adults and shows slight histological changes in some patients, which have been defined as major and minor criteria. The genetic cause is unknown in most cases. The diagnosis of HH, as defined by genetic, histological, and phenotypic features, has important implications for patient management and outcome.
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Affiliation(s)
- 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
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, 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
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark.
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Liberatore RDR, Monteiro ICM, Pileggi FDO, Canesin WC, Sbragia L. Congenital hyperinsulinism and surgical outcome in a single tertiary center in Brazil. J Pediatr (Rio J) 2024; 100:163-168. [PMID: 37866397 PMCID: PMC10943321 DOI: 10.1016/j.jped.2023.09.005] [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] [Received: 08/09/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVE Congenital hyperinsulinism (CHI) is a heterogeneous genetic disease characterized by increased insulin secretion and causes persistent hypoglycemia in neonates and infants due to dysregulation of insulin secretion by pancreatic β cells. Babies with severe hypoglycemia and for whom medical treatment has been ineffective usually require surgical treatment with near-total pancreatectomy. To evaluate the clinical and surgical aspects affecting survival outcomes in babies diagnosed with CHI in a single tertiary care center. METHODS Retrospective Cohort study involving a single university tertiary center for the treatment of CHI. The authors study the demographics, clinical, laboratory, and surgical outcomes of this casuistic. RESULTS 61 % were female, 39 % male, Birth weight: 3576 g (±313); Age of onset of symptoms: from the 2nd hour of life to 28 days; Time between diagnosis and surgery ranged between 10 and 60 days; Medical clinical treatment, all patients received glucose solution with a continuous glucose infusion and diazoxide. 81 % of the patients used corticosteroids, 77 %. thiazide, 72 % octreotide, 27 % nifedipine; Neurological sequelae during development and growth: 54 % had some degree of delay in neuropsychomotor development, 27 % obesity. Surgery was performed open in 6 and 12 minimally invasive surgery (MIS). HISTOPATHOLOGY 2 focal and 16 diffuse, Length of stay (days) was lower in MIS (p < 0.05). Survival was 100 %. CONCLUSIONS CHI is a rare and difficult-to-manage tumor that must be performed in a multidisciplinary and tertiary center. Most surgical results are good and the laparoscopic approach to disease has been the best choice for patients.
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Affiliation(s)
- Raphael Del Roio Liberatore
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Endocrinologia Pediátrica e Departamento de Puericultura e Pediatria, Ribeirão Preto, SP, Brazil
| | - Isabella Christina Mazzaro Monteiro
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Endocrinologia Pediátrica e Departamento de Puericultura e Pediatria, Ribeirão Preto, SP, Brazil
| | - Flavio de Oliveira Pileggi
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Cirurgia Pediátrica, Departamento de Cirurgia e Anatomia, Ribeirão Preto, SP, Brazil
| | - Wellen Cristina Canesin
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Cirurgia Pediátrica, Departamento de Cirurgia e Anatomia, Ribeirão Preto, SP, Brazil
| | - Lourenço Sbragia
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Cirurgia Pediátrica, Departamento de Cirurgia e Anatomia, Ribeirão Preto, SP, Brazil.
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Shaikh MG, Lucas-Herald AK, Dastamani A, Salomon Estebanez M, Senniappan S, Abid N, Ahmad S, Alexander S, Avatapalle B, Awan N, Blair H, Boyle R, Chesover A, Cochrane B, Craigie R, Cunjamalay A, Dearman S, De Coppi P, Erlandson-Parry K, Flanagan SE, Gilbert C, Gilligan N, Hall C, Houghton J, Kapoor R, McDevitt H, Mohamed Z, Morgan K, Nicholson J, Nikiforovski A, O'Shea E, Shah P, Wilson K, Worth C, Worthington S, Banerjee I. Standardised practices in the networked management of congenital hyperinsulinism: a UK national collaborative consensus. Front Endocrinol (Lausanne) 2023; 14:1231043. [PMID: 38027197 PMCID: PMC10646160 DOI: 10.3389/fendo.2023.1231043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 09/04/2023] [Indexed: 12/01/2023] Open
Abstract
Congenital hyperinsulinism (CHI) is a condition characterised by severe and recurrent hypoglycaemia in infants and young children caused by inappropriate insulin over-secretion. CHI is of heterogeneous aetiology with a significant genetic component and is often unresponsive to standard medical therapy options. The treatment of CHI can be multifaceted and complex, requiring multidisciplinary input. It is important to manage hypoglycaemia in CHI promptly as the risk of long-term neurodisability arising from neuroglycopaenia is high. The UK CHI consensus on the practice and management of CHI was developed to optimise and harmonise clinical management of patients in centres specialising in CHI as well as in non-specialist centres engaged in collaborative, networked models of care. Using current best practice and a consensus approach, it provides guidance and practical advice in the domains of diagnosis, clinical assessment and treatment to mitigate hypoglycaemia risk and improve long term outcomes for health and well-being.
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Affiliation(s)
- M. Guftar Shaikh
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Angela K. Lucas-Herald
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Antonia Dastamani
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Maria Salomon Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Noina Abid
- Department of Paediatric Endocrinology, Royal Belfast Hospital for Sick Children, Belfast, United Kingdom
| | - Sumera Ahmad
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Sophie Alexander
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Bindu Avatapalle
- Department of Paediatric Endocrinology and Diabetes, University Hospital of Wales, Cardiff, United Kingdom
| | - Neelam Awan
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Hester Blair
- Department of Dietetics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Roisin Boyle
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Alexander Chesover
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Barbara Cochrane
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Ross Craigie
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Annaruby Cunjamalay
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Sarah Dearman
- The Children’s Hyperinsulinism Charity, Accrington, United Kingdom
| | - Paolo De Coppi
- SNAPS, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- NIHR BRC UCL Institute of Child Health, London, United Kingdom
| | - Karen Erlandson-Parry
- Department of Paediatric Endocrinology, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Sarah E. Flanagan
- Department of Clinical and Biomedical Science, University of Exeter, Exeter, United Kingdom
| | - Clare Gilbert
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Niamh Gilligan
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Caroline Hall
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Jayne Houghton
- Exeter Genomics Laboratory, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - Ritika Kapoor
- Department of Paediatric Endocrinology, Faculty of Medicine and Life Sciences, King’s College London, King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Helen McDevitt
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Zainab Mohamed
- Department of Paediatric Endocrinology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Kate Morgan
- Department of Paediatric Endocrinology and Diabetes, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Jacqueline Nicholson
- Paediatric Psychosocial Service, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Ana Nikiforovski
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Elaine O'Shea
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Pratik Shah
- Department of Paediatric Endocrinology, Barts Health NHS Trust, Royal London Children’s Hospital, London, United Kingdom
| | - Kirsty Wilson
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Sarah Worthington
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
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Non-coding variants disrupting a tissue-specific regulatory element in HK1 cause congenital hyperinsulinism. Nat Genet 2022; 54:1615-1620. [PMID: 36333503 PMCID: PMC7614032 DOI: 10.1038/s41588-022-01204-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 09/16/2022] [Indexed: 11/06/2022]
Abstract
Gene expression is tightly regulated, with many genes exhibiting cell-specific silencing when their protein product would disrupt normal cellular function1. This silencing is largely controlled by non-coding elements, and their disruption might cause human disease2. We performed gene-agnostic screening of the non-coding regions to discover new molecular causes of congenital hyperinsulinism. This identified 14 non-coding de novo variants affecting a 42-bp conserved region encompassed by a regulatory element in intron 2 of the hexokinase 1 gene (HK1). HK1 is widely expressed across all tissues except in the liver and pancreatic beta cells and is thus termed a 'disallowed gene' in these specific tissues. We demonstrated that the variants result in a loss of repression of HK1 in pancreatic beta cells, thereby causing insulin secretion and congenital hyperinsulinism. Using epigenomic data accessed from public repositories, we demonstrated that these variants reside within a regulatory region that we determine to be critical for cell-specific silencing. Importantly, this has revealed a disease mechanism for non-coding variants that cause inappropriate expression of a disallowed gene.
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Congenital hyperinsulinism: localization of a focal lesion with 18F-FDOPA positron emission tomography. Pediatr Radiol 2022; 52:693-701. [PMID: 34668049 DOI: 10.1007/s00247-021-05206-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/29/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
Hyperinsulinemic hypoglycemia of infancy, also known as congenital hyperinsulinism, is a group of disorders characterized by dysregulated insulin release. Neonates with severe, persistent hyperinsulinemic hypoglycemia who are unresponsive to medical therapy require pancreatectomy to prevent brain damage from hypoglycemia. To date, multiple genetic mutations and syndromes and several unique histopathological entities have been identified in children with hyperinsulinism. Histopathology is characterized as diffuse, focal or atypical. Surgical resection of a focal lesion results in a cure in up to 97% of these children. Imaging with 6-fluoro-(18F)-L-3,4-dihydroxyphenylalanine (18F-FDOPA) positron emission tomography (PET) is the test of choice for identifying and localizing a focal lesion and has proved to be an invaluable guide for surgical resection. Genetic evaluation is essential for determining who will benefit from PET imaging. This article provides an approach to determine who should be imaged, how to set up a protocol and how to interpret the imaging findings. The diagnosis and management of this disorder require a multidisciplinary approach to prevent brain damage from hypoglycemia.
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6
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Melikyan M, Gubaeva D, Nikitina I, Ryzhkova D, Mitrofanova L, Yukhacheva D, Pershin D, Shcherbina A, Vasilyev E, Proshchina A, Krivova Y, Tiulpakov A. The coincidence of two rare diseases with opposite metabolic phenotype: a child with congenital hyperinsulinism and Bloom syndrome. J Pediatr Endocrinol Metab 2022; 35:405-409. [PMID: 34700371 DOI: 10.1515/jpem-2021-0464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/06/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Congenital hyperinsulinism (CHI) is a group of rare genetic disorders characterized by insulin overproduction. CHI causes life-threatening hypoglycemia in neonates and infants. Bloom syndrome is a rare autosomal recessive disorder caused by mutations in the BLM gene resulting in genetic instability and an elevated rate of spontaneous sister chromatid exchanges. It leads to insulin resistance, early-onset diabetes, dyslipidemia, growth delay, immune deficiency and cancer predisposition. Recent studies demonstrate that the BLM gene is highly expressed in pancreatic islet cells and its mutations can alter the expression of other genes which are associated with apoptosis control and cell proliferation. CASE PRESENTATION A 5-month-old female patient from consanguineous parents presented with drug-resistant CHI and dysmorphic features. Genetic testing revealed a homozygous mutation in the KCNJ11 gene and an additional homozygous mutation in the BLM gene. While 18F-DOPA PET scan images were consistent with a focal CHI form and intraoperative frozen-section histopathology was consistent with diffuse CHI form, postoperative histopathological examination revealed features of an atypical form. CONCLUSIONS In our case, the patient carries two distinct diseases with opposite metabolic phenotypes.
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Affiliation(s)
| | | | - Irina Nikitina
- Almazov National Medical Research Center, Saint-Petersburg, Russia
| | - Daria Ryzhkova
- Almazov National Medical Research Center, Saint-Petersburg, Russia
| | | | - Daria Yukhacheva
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Dmitry Pershin
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna Shcherbina
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | | | | | | | - Anatoly Tiulpakov
- Endocrinology Research Center, Moscow, Russia.,Research Center for Medical Genetics, Moscow, Russia
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Giri D, Hawton K, Senniappan S. Congenital hyperinsulinism: recent updates on molecular mechanisms, diagnosis and management. J Pediatr Endocrinol Metab 2022; 35:279-296. [PMID: 34547194 DOI: 10.1515/jpem-2021-0369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/30/2021] [Indexed: 12/20/2022]
Abstract
Congenital hyperinsulinism (CHI) is a rare disease characterized by an unregulated insulin release, leading to hypoglycaemia. It is the most frequent cause of persistent and severe hypoglycaemia in the neonatal period and early childhood. Mutations in 16 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, KCNQ1, CACNA1D, FOXA2, EIF2S3, PGM1 and PMM2) that are involved in regulating the insulin secretion from pancreatic β-cells have been described to be responsible for the underlying molecular mechanisms of CHI. CHI can also be associated with specific syndromes and can be secondary to intrauterine growth restriction (IUGR), maternal diabetes, birth asphyxia, etc. It is important to diagnose and promptly initiate appropriate management as untreated hypoglycaemia can be associated with significant neurodisability. CHI can be histopathologically classified into diffuse, focal and atypical forms. Advances in molecular genetics, imaging techniques (18F-fluoro-l-dihydroxyphenylalanine positron emission tomography/computed tomography scanning), novel medical therapies and surgical advances (laparoscopic pancreatectomy) have changed the management and improved the outcome of patients with CHI. This review article provides an overview of the background, clinical presentation, diagnosis, molecular genetics and therapy for children with different forms of CHI.
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Affiliation(s)
- Dinesh Giri
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.,University of Bristol, Bristol, UK
| | - Katherine Hawton
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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8
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Dastamani A, Yau D, Gilbert C, Morgan K, De Coppi P, Craigie RJ, Bomanji J, Biassoni L, Sajjan R, Flanagan SE, Houghton JAL, Senniappan S, Didi M, Dunne MJ, Banerjee I, Shah P. Variation in Glycaemic Outcomes in Focal Forms of Congenital Hyperinsulinism - The UK Perspective. J Endocr Soc 2022; 6:bvac033. [PMID: 35592516 PMCID: PMC9113085 DOI: 10.1210/jendso/bvac033] [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: 11/27/2019] [Indexed: 11/19/2022] Open
Abstract
Context In focal congenital hyperinsulinism (CHI), localized clonal expansion of pancreatic β-cells causes excess insulin secretion and severe hypoglycemia. Surgery is curative, but not all lesions are amenable to surgery. Objective We describe surgical and nonsurgical outcomes of focal CHI in a national cohort. Methods Patients with focal CHI were retrospectively reviewed at 2 specialist centers, 2003-2018. Results Of 59 patients with focal CHI, 57 had heterozygous mutations in ABCC8/KCNJ11 (51 paternally inherited, 6 de novo). Fluorine-18 L-3,4 dihydroxyphenylalanine positron emission tomography computed tomography scan identified focal lesions in 51 patients. In 5 patients, imaging was inconclusive; the diagnosis was established by frozen section histopathology in 3 patients, a lesion was not identified in 1 patient, and 1 declined surgery. Most patients (n = 56) were unresponsive to diazoxide, of whom 33 were unresponsive or partially responsive to somatostatin receptor analog (SSRA) therapy. Fifty-five patients underwent surgery: 40 had immediate resolution of CHI, 10 had persistent hypoglycemia and a focus was not identified on biopsy in 5. In the 10 patients with persistent hypoglycemia, 7 underwent further surgery with resolution in 4 and ongoing hypoglycemia requiring SSRA in 3. Nine (15% of cohort) patients (1 complex surgical access; 4 biopsy negative; 4 declined surgery) were managed conservatively; medication was discontinued in 8 children at a median (range) age 2.4 (1.5-7.7) years and 1 remains on SSRA at 16 years with improved fasting tolerance and reduction in SSRA dose. Conclusion Despite a unifying genetic basis of disease, we report inherent heterogeneity in focal CHI patients impacting outcomes of both surgical and medical management.
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Affiliation(s)
- Antonia Dastamani
- Endocrinology Department, Great Ormond Street Hospital for Children, London, UK
| | - Daphne Yau
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Clare Gilbert
- Endocrinology Department, Great Ormond Street Hospital for Children, London, UK
| | - Kate Morgan
- Endocrinology Department, Great Ormond Street Hospital for Children, London, UK
| | - Paolo De Coppi
- Department of Surgery, Great Ormond Street Hospital for Children, London, UK
| | - Ross J Craigie
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK
| | - Jamshed Bomanji
- Nuclear Medicine Department, UCL Hospitals NHS Foundation Trust, London, UK
| | - Lorenzo Biassoni
- Nuclear Medicine Department, Great Ormond Street Hospital for Children, London, UK
| | - Rakesh Sajjan
- Nuclear Medicine Department, Royal Manchester Children's Hospital, Manchester, UK
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Jayne A L Houghton
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Mohammed Didi
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital NHS Trust, Liverpool, UK
| | - Mark J Dunne
- School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Pratik Shah
- Endocrinology Department, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Programme, University College London (UCL) Great Ormond Street Institute of Child Health, London, UK
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9
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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] [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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10
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Boss M, Rottenburger C, Brenner W, Blankenstein O, Prasad V, Prasad S, de Coppi P, Kühnen P, Buitinga M, Nuutila P, Otonkoski T, Hussain K, Brom M, Eek A, Bomanji JB, Shah P, Gotthardt M. 68Ga-NODAGA-exendin-4 PET improves the detection of focal congenital hyperinsulinism. J Nucl Med 2021; 63:310-315. [PMID: 34215672 PMCID: PMC8805776 DOI: 10.2967/jnumed.121.262327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/05/2021] [Indexed: 11/18/2022] Open
Abstract
Surgery with curative intent can be offered to congenital hyperinsulinism (CHI) patients, provided that the lesion is focal. Radiolabeled exendin-4 specifically binds the glucagonlike peptide 1 receptor on pancreatic β-cells. In this study, we compared the performance of 18F-DOPA PET/CT, the current standard imaging method for CHI, and PET/CT with the new tracer 68Ga-NODAGA-exendin-4 in the preoperative detection of focal CHI. Methods: Nineteen CHI patients underwent both 18F-DOPA PET/CT and 68Ga-NODAGA-exendin-4 PET/CT before surgery. The images were evaluated in 3 settings: a standard clinical reading, a masked expert reading, and a joint reading. The target (lesion)-to-nontarget (normal pancreas) ratio was determined using SUVmax. Image quality was rated by pediatric surgeons in a questionnaire. Results: Fourteen of 19 patients having focal lesions underwent surgery. On the basis of clinical readings, the sensitivity of 68Ga-NODAGA-exendin-4 PET/CT (100%; 95% CI, 77%–100%) was higher than that of 18F-DOPA PET/CT (71%; 95% CI, 42%–92%). Interobserver agreement between readings was higher for 68Ga-NODAGA-exendin-4 than for 18F-DOPA PET/CT (Fleiss κ = 0.91 vs. 0.56). 68Ga-NODAGA-exendin-4 PET/CT provided significantly (P = 0.021) higher target-to-nontarget ratios (2.02 ± 0.65) than did 18F-DOPA PET/CT (1.40 ± 0.40). On a 5-point scale, pediatric surgeons rated 68Ga-NODAGA-exendin-4 PET/CT as superior to 18F-DOPA PET/CT. Conclusion: For the detection of focal CHI, 68Ga-NODAGA-exendin-4 PET/CT has higher clinical sensitivity and better interobserver correlation than 18F-DOPA PET/CT. Better contrast and image quality make 68Ga-NODAGA-exendin-4 PET/CT superior to 18F-DOPA PET/CT in surgeons’ intraoperative quest for lesion localization.
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Affiliation(s)
- Marti Boss
- Radboud University Medical Center, Netherlands
| | | | | | | | | | | | - Paolo de Coppi
- Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | | | | | | | | | | | | | | | | | - Pratik Shah
- Great Ormond Street Hospital for Children NHS Foundation Trust
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11
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Lithovius V, Saarimäki-Vire J, Balboa D, Ibrahim H, Montaser H, Barsby T, Otonkoski T. SUR1-mutant iPS cell-derived islets recapitulate the pathophysiology of congenital hyperinsulinism. Diabetologia 2021; 64:630-640. [PMID: 33404684 DOI: 10.1007/s00125-020-05346-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/13/2020] [Indexed: 12/27/2022]
Abstract
AIMS/HYPOTHESIS Congenital hyperinsulinism caused by mutations in the KATP-channel-encoding genes (KATPHI) is a potentially life-threatening disorder of the pancreatic beta cells. No optimal medical treatment is available for patients with diazoxide-unresponsive diffuse KATPHI. Therefore, we aimed to create a model of KATPHI using patient induced pluripotent stem cell (iPSC)-derived islets. METHODS We derived iPSCs from a patient carrying a homozygous ABCC8V187D mutation, which inactivates the sulfonylurea receptor 1 (SUR1) subunit of the KATP-channel. CRISPR-Cas9 mutation-corrected iPSCs were used as controls. Both were differentiated to stem cell-derived islet-like clusters (SC-islets) and implanted into NOD-SCID gamma mice. RESULTS SUR1-mutant and -corrected iPSC lines both differentiated towards the endocrine lineage, but SUR1-mutant stem cells generated 32% more beta-like cells (SC-beta cells) (64.6% vs 49.0%, p = 0.02) and 26% fewer alpha-like cells (16.1% vs 21.8% p = 0.01). SUR1-mutant SC-beta cells were 61% more proliferative (1.23% vs 0.76%, p = 0.006), and this phenotype could be induced in SUR1-corrected cells with pharmacological KATP-channel inactivation. The SUR1-mutant SC-islets secreted 3.2-fold more insulin in low glucose conditions (0.0174% vs 0.0054%/min, p = 0.0021) and did not respond to KATP-channel-acting drugs in vitro. Mice carrying grafts of SUR1-mutant SC-islets presented with 38% lower fasting blood glucose (4.8 vs 7.7 mmol/l, p = 0.009) and their grafts failed to efficiently shut down insulin secretion during induced hypoglycaemia. Explanted SUR1-mutant grafts displayed an increase in SC-beta cell proportion and SC-beta cell nucleomegaly, which was independent of proliferation. CONCLUSIONS/INTERPRETATION We have created a model recapitulating the known pathophysiology of KATPHI both in vitro and in vivo. We have also identified a novel role for KATP-channel activity during human islet development. This model will enable further studies for the improved understanding and clinical management of KATPHI without the need for primary patient tissue.
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Affiliation(s)
- Väinö Lithovius
- Stem Cells and Metabolism Research Program in the Faculty of Medicine of the University of Helsinki, Helsinki, Finland.
| | - Jonna Saarimäki-Vire
- Stem Cells and Metabolism Research Program in the Faculty of Medicine of the University of Helsinki, Helsinki, Finland
| | - Diego Balboa
- Stem Cells and Metabolism Research Program in the Faculty of Medicine of the University of Helsinki, Helsinki, Finland
- Bioinformatics and Genomics Program, Centre for Genomic Regulation (CRG), The Barcelona Institute of Science and Technology (BIST), Barcelona, Spain
| | - Hazem Ibrahim
- Stem Cells and Metabolism Research Program in the Faculty of Medicine of the University of Helsinki, Helsinki, Finland
| | - Hossam Montaser
- Stem Cells and Metabolism Research Program in the Faculty of Medicine of the University of Helsinki, Helsinki, Finland
| | - Tom Barsby
- Stem Cells and Metabolism Research Program in the Faculty of Medicine of the University of Helsinki, Helsinki, Finland
| | - Timo Otonkoski
- Stem Cells and Metabolism Research Program in the Faculty of Medicine of the University of Helsinki, Helsinki, Finland.
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12
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Mitrofanova LB, Perminova AA, Ryzhkova DV, Sukhotskaya AA, Bairov VG, Nikitina IL. Differential Morphological Diagnosis of Various Forms of Congenital Hyperinsulinism in Children. Front Endocrinol (Lausanne) 2021; 12:710947. [PMID: 34497584 PMCID: PMC8419459 DOI: 10.3389/fendo.2021.710947] [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: 05/17/2021] [Accepted: 08/04/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Congenital hyperinsulinism (CHI) has diffuse (CHI-D), focal (CHI-F) and atypical (CHI-A) forms. Surgical management depends on preoperative [18F]-DOPA PET/CT and intraoperative morphological differential diagnosis of CHI forms. Objective: to improve differential diagnosis of CHI forms by comparative analysis [18F]-DOPA PET/CT data, as well as cytological, histological and immunohistochemical analysis (CHIA). MATERIALS AND METHODS The study included 35 CHI patients aged 3.2 ± 2.0 months; 10 patients who died from congenital heart disease at the age of 3.2 ± 2.9 months (control group). We used PET/CT, CHIA of pancreas with antibodies to ChrA, insulin, Isl1, Nkx2.2, SST, NeuroD1, SSTR2, SSTR5, DR1, DR2, DR5; fluorescence microscopy with NeuroD1/ChrA, Isl1/insulin, insulin/SSTR2, DR2/NeuroD1 cocktails. RESULTS Intraoperative examination of pancreatic smears showed the presence of large nuclei, on average, in: 14.5 ± 3.5 cells of CHI-F; 8.4 ± 1.1 of CHI-D; and 4.5 ± 0.7 of control group (from 10 fields of view, x400). The percentage of Isl1+ and NeuroD1+endocrinocytes significantly differed from that in the control for all forms of CHI. The percentage of NeuroD1+exocrinocytes was also significantly higher than in the control. The proportion of ChrA+ and DR2+endocrinocytes was higher in CHI-D than in CHI-F, while the proportion of insulin+cells was higher in CHI-A. The number of SST+cells was significantly higher in CHI-D and CHI-F than in CHI-A. CONCLUSION For intraoperative differential diagnosis of CHI forms, in addition to frozen sections, quantitative cytological analysis can be used. In quantitative immunohistochemistry, CHI forms differ in the expression of ChrA, insulin, SST and DR2. The development of a NeuroD1 inhibitor would be advisable for targeted therapy of CHI.
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13
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Worth C, Yau D, Salomon Estebanez M, O'Shea E, Cosgrove K, Dunne M, Banerjee I. Complexities in the medical management of hypoglycaemia due to congenital hyperinsulinism. Clin Endocrinol (Oxf) 2020; 92:387-395. [PMID: 31917867 DOI: 10.1111/cen.14152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/03/2020] [Accepted: 01/05/2020] [Indexed: 12/12/2022]
Abstract
Congenital Hyperinsulinism (CHI) is a rare disease of hypoglycaemia but is the most common form of recurrent and severe hypoglycaemia causing brain injury and neurodisability in children. The management of CHI is complex due to the limited choice of medications, all with a limited therapeutic window, often lacking efficacy and associated with serious side effects. The therapeutic strategy in CHI is to recognize and treat hypoglycaemia promptly, thereby optimizing long-term neurological outcomes; this should be achieved through individualized treatment plans that deliver glycaemic stability while minimizing side effects. Further, such a strategy should consider the likelihood of reduction in disease severity over time, with dose adjustments and medication withdrawal as indicated to optimize both safety and tolerability. The option for pancreatic surgery should also be considered in specific circumstances as appropriate for the patient's best long-term interests.
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Affiliation(s)
- Christopher Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Daphne Yau
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Department of Pediatrics, Division of Endocrinology, Jim Pattison Children's Hospital, Saskatoon, SK, Canada
| | - Maria Salomon Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Elaine O'Shea
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Karen Cosgrove
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mark Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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14
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Zobel MJ, McFarland C, Ferrera-Cook CT, Padilla BE. Surgical management of medically-refractory hyperinsulinism. Am J Surg 2019; 219:947-951. [PMID: 31757439 DOI: 10.1016/j.amjsurg.2019.09.003] [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: 06/03/2019] [Revised: 08/21/2019] [Accepted: 09/08/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) and insulinomas are the most common causes of medically-refractory pediatric hyperinsulinism. METHODS Children with CHI or insulinoma treated from 1/1/2014-1/1/2019 at an academic center were retrospectively analyzed. Primary outcome was persistent intravenous dextrose requirement at discharge. RESULTS Eleven patients were identified: six with diffuse-type CHI, three with focal-type CHI, two with insulinoma. Median age at diagnosis was 20 days (1 day-16 years). Preoperative functional imaging (18F-Fluoro-l-DOPA PET-CT scan) accurately localized 66% of focal-type CHI lesions. All patients with focal-type CHI and insulinoma were cured by local resection. All patients with diffuse-type CHI underwent near-total pancreatectomy (NTP): four patients were cured of hyperinsulinism, of which 2 developed insulin-dependent diabetes, while two patients were palliated to home enteral glucose infusion. CONCLUSIONS Localized resection cures children with focal, insulin-secreting lesions. NTP may cure diffuse-type CHI; potential complications include diabetes, exocrine insufficiency, and persistent hypoglycemia from residual hypersecreting pancreatic tissue. SUMMARY Congenital hyperinsulinism (CHI) and insulinomas are the most common causes of medically-refractory pediatric hyperinsulinism, causing potential complications including permanent brain injury. 18F-Fluoro-l-DOPA PET-CT scan can be used to localize focal insulin-secretion lesions preoperatively. Focal-type CHI and insulinoma are cured by localized resection. Diffuse-type CHI requires near-total pancreatectomy for cure, but complications include diabetes, exocrine insufficiency, or persistent hypoglycemia from residual foci of hypersecreting pancreatic tissue.
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Affiliation(s)
- Michael J Zobel
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, USA
| | - Carrie McFarland
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, USA
| | - Christine T Ferrera-Cook
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, USA
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15
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Houghton JA, Banerjee I, Shaikh G, Jabbar S, Laver TW, Cheesman E, Chinnoy A, Yau D, Salomon-Estebanez M, Dunne MJ, Flanagan SE. Unravelling the genetic causes of mosaic islet morphology in congenital hyperinsulinism. JOURNAL OF PATHOLOGY CLINICAL RESEARCH 2019; 6:12-16. [PMID: 31577849 PMCID: PMC6966704 DOI: 10.1002/cjp2.144] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/29/2019] [Accepted: 09/11/2019] [Indexed: 12/16/2022]
Abstract
Congenital hyperinsulinism (CHI) causes dysregulated insulin secretion which can lead to life‐threatening hypoglycaemia if not effectively managed. CHI can be sub‐classified into three distinct groups: diffuse, focal and mosaic pancreatic disease. Whilst the underlying causes of diffuse and focal disease have been widely characterised, the genetic basis of mosaic pancreatic disease is not known. To gain new insights into the underlying disease processes of mosaic‐CHI we studied the islet tissue histopathology derived from limited surgical resection from the tail of the pancreas in a patient with CHI. The underlying genetic aetiology was investigated using a combination of high depth next‐generation sequencing, microsatellite analysis and p57kip2 immunostaining. Histopathology of the pancreatic tissue confirmed the presence of a defined area associated with marked islet hypertrophy and a cytoarchitecture distinct from focal CHI but compatible with mosaic CHI localised to a discrete region within the pancreas. Analysis of DNA extracted from the lesion identified a de novo mosaic ABCC8 mutation and mosaic paternal uniparental disomy which were not present in leukocyte DNA or the surrounding unaffected pancreatic tissue. This study provides the first description of two independent disease‐causing somatic genetic events occurring within the pancreas of an individual with localised mosaic CHI. Our findings increase knowledge of the genetic causes of islet disease and provide further insights into the underlying developmental changes associated with β‐cell expansion in CHI.
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Affiliation(s)
- Jayne Al Houghton
- The Genomics Laboratory, Royal Devon and Exeter Foundation Hospital, Exeter, UK.,Molecular Genetics, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.,Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Guftar Shaikh
- Department of Paediatric Endocrinology, Royal Hospital for Children, Glasgow, UK
| | - Shamila Jabbar
- Department of Paediatric Pathology, Royal Manchester Children's Hospital, Manchester, UK
| | - Thomas W Laver
- Molecular Genetics, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Edmund Cheesman
- Department of Paediatric Pathology, Royal Manchester Children's Hospital, Manchester, UK
| | - Amish Chinnoy
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Daphne Yau
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Mark J Dunne
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Sarah E Flanagan
- Molecular Genetics, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
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16
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Chinoy A, Banerjee I, Flanagan SE, Ellard S, Han B, Mohamed Z, Dunne MJ, Bitetti S. Focal Congenital Hyperinsulinism as a Cause for Sudden Infant Death. Pediatr Dev Pathol 2019; 22:65-69. [PMID: 29558846 DOI: 10.1177/1093526618765376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Congenital hyperinsulinism (CHI) is the commonest cause of persistent and severe hypoglycemia in infancy due to unregulated insulin secretion from pancreatic β-cells. Prompt early diagnosis is important, as insulin reduces glucose supply to the brain, resulting in significant brain injury and risk of death. Histologically, CHI has focal and diffuse forms; in focal CHI, an inappropriate level of insulin is secreted from localized β-cell hyperplasia. We report a 4-month-old male infant, who presented with sudden illness and collapse without a recognized cause and died. Postmortem examination revealed pancreatic histopathology compatible with focal CHI. Immunofluoresence staining showed limited expression of p57kip2 β-cells reinforcing the diagnosis. Mutation testing for genes associated with CHI from DNA from the focal lesion was negative. This case highlights the recognition of focal CHI as a possible cause for sudden infant death. In children dying suddenly and unexpectedly, postmortem pancreatic sections should be carefully examined for focal CHI.
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Affiliation(s)
- Amish Chinoy
- 1 Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Indraneel Banerjee
- 1 Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Sarah E Flanagan
- 2 Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Sian Ellard
- 2 Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Bing Han
- 3 Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Zainab Mohamed
- 1 Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.,3 Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Mark J Dunne
- 3 Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Stefania Bitetti
- 4 Department of Paediatric Histopathology, St Mary's Hospital, Manchester, UK
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17
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Banerjee I, Salomon‐Estebanez M, Shah P, Nicholson J, Cosgrove KE, Dunne MJ. Therapies and outcomes of congenital hyperinsulinism-induced hypoglycaemia. Diabet Med 2019; 36:9-21. [PMID: 30246418 PMCID: PMC6585719 DOI: 10.1111/dme.13823] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 12/01/2022]
Abstract
Congenital hyperinsulinism is a rare disease, but is the most frequent cause of persistent and severe hypoglycaemia in early childhood. Hypoglycaemia caused by excessive and dysregulated insulin secretion (hyperinsulinism) from disordered pancreatic β cells can often lead to irreversible brain damage with lifelong neurodisability. Although congenital hyperinsulinism has a genetic cause in a significant proportion (40%) of children, often being the result of mutations in the genes encoding the KATP channel (ABCC8 and KCNJ11), not all children have severe and persistent forms of the disease. In approximately half of those without a genetic mutation, hyperinsulinism may resolve, although timescales are unpredictable. From a histopathology perspective, congenital hyperinsulinism is broadly grouped into diffuse and focal forms, with surgical lesionectomy being the preferred choice of treatment in the latter. In contrast, in diffuse congenital hyperinsulinism, medical treatment is the best option if conservative management is safe and effective. In such cases, children receiving treatment with drugs, such as diazoxide and octreotide, should be monitored for side effects and for signs of reduction in disease severity. If hypoglycaemia is not safely managed by medical therapy, subtotal pancreatectomy may be required; however, persistent hypoglycaemia may continue after surgery and diabetes is an inevitable consequence in later life. It is important to recognize the negative cognitive impact of early-life hypoglycaemia which affects half of all children with congenital hyperinsulinism. Treatment options should be individualized to the child/young person with congenital hyperinsulinism, with full discussion regarding efficacy, side effects, outcomes and later life impact.
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Affiliation(s)
- I. Banerjee
- Department of Paediatric EndocrinologyRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - M. Salomon‐Estebanez
- Department of Paediatric EndocrinologyRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - P. Shah
- Endocrinology DepartmentGreat Ormond Street Hospital for ChildrenNHS Foundation TrustLondonUK
| | - J. Nicholson
- Paediatric Psychosocial DepartmentRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
| | - K. E. Cosgrove
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - M. J. Dunne
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
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Abstract
Hyperinsulinaemic hypoglycaemia (HH) is a heterogeneous condition with dysregulated insulin secretion which persists in the presence of low blood glucose levels. It is the most common cause of severe and persistent hypoglycaemia in neonates and children. Recent advances in genetics have linked congenital HH to mutations in 14 different genes that play a key role in regulating insulin secretion (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1, PPM2, CACNA1D, FOXA2). Histologically, congenital HH can be divided into 3 types: diffuse, focal and atypical. Due to the biochemical basis of this condition, it is essential to diagnose and treat HH promptly in order to avoid the irreversible hypoglycaemic brain damage. Recent advances in the field of HH include new rapid molecular genetic testing, novel imaging methods (18F-DOPA PET/CT), novel medical therapy (long-acting octreotide formulations, mTOR inhibitors, GLP-1 receptor antagonists) and surgical approach (laparoscopic surgery). The review article summarizes the current diagnostic methods and management strategies for HH in children.
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Affiliation(s)
- Sonya Galcheva
- Dept. of Paediatrics, Varna Medical University/University Hospital "St. Marina", Varna, Bulgaria
| | - Sara Al-Khawaga
- Dept. of Paediatric Medicine, Division of Endocrinology, Sidra Medical & Research Center, Doha, Qatar
| | - Khalid Hussain
- Dept. of Paediatric Medicine, Division of Endocrinology, Sidra Medical & Research Center, Doha, Qatar.
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19
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Craigie RJ, Salomon-Estebanez M, Yau D, Han B, Mal W, Newbould M, Cheesman E, Bitetti S, Mohamed Z, Sajjan R, Padidela R, Skae M, Flanagan S, Ellard S, Cosgrove KE, Banerjee I, Dunne MJ. Clinical Diversity in Focal Congenital Hyperinsulinism in Infancy Correlates With Histological Heterogeneity of Islet Cell Lesions. Front Endocrinol (Lausanne) 2018; 9:619. [PMID: 30386300 PMCID: PMC6199412 DOI: 10.3389/fendo.2018.00619] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 09/27/2018] [Indexed: 01/11/2023] Open
Abstract
Background: Congenital Hyperinsulinism (CHI) is an important cause of severe and persistent hypoglycaemia in infancy and childhood. The focal form (CHI-F) of CHI can be potentially cured by pancreatic lesionectomy. While diagnostic characteristics of CHI-F pancreatic histopathology are well-recognized, correlation with clinical phenotype has not been established. Aims: We aimed to correlate the diversity in clinical profiles of patients with islet cell organization in CHI-F pancreatic tissue. Methods: Clinical datasets were obtained from 25 patients with CHI-F due to ABCC8/KCNJ11 mutations. 18F-DOPA PET-CT was used to localize focal lesions prior to surgery. Immunohistochemistry was used to support protein expression studies. Results: In 28% (n = 7) of patient tissues focal lesions were amorphous and projected into adjoining normal pancreatic tissue without clear delineation from normal tissue. In these cases, severe hypoglycaemia was detected within, on average, 2.8 ± 0.8 (range 1-7) days following birth. By contrast, in 72% (n = 18) of tissues focal lesions were encapsulated within a defined matrix capsule. In this group, the onset of severe hypoglycaemia was generally delayed; on average 46.6 ± 14.3 (range 1-180) days following birth. For patients with encapsulated lesions and later-onset hypoglycaemia, we found that surgical procedures were curative and less complex. Conclusion: CHI-F is associated with heterogeneity in the organization of focal lesions, which correlates well with clinical presentation and surgical outcomes.
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Affiliation(s)
- Ross J. Craigie
- Paediatric Surgery, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Maria Salomon-Estebanez
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
- Paediatric Endocrinology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Daphne Yau
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
- Paediatric Endocrinology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Bing Han
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Walaa Mal
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Melanie Newbould
- Paediatric Histopathology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Edmund Cheesman
- Paediatric Histopathology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Stefania Bitetti
- Paediatric Histopathology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Zainab Mohamed
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
- Paediatric Endocrinology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Rakesh Sajjan
- Nuclear Medicine, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Raja Padidela
- Paediatric Endocrinology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Mars Skae
- Paediatric Endocrinology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Sarah Flanagan
- Molecular Genetics, Royal Devon & Exeter NHS Foundation Trust, University of Exeter Medical School, Royal Devon & Exeter Hospital, Exeter, United Kingdom
| | - Sian Ellard
- Molecular Genetics, Royal Devon & Exeter NHS Foundation Trust, University of Exeter Medical School, Royal Devon & Exeter Hospital, Exeter, United Kingdom
| | - Karen E. Cosgrove
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
| | - Indraneel Banerjee
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
- Paediatric Endocrinology, Royal Manchester Children's Hospital, University Manchester NHS Foundation Trust (MFT), Manchester, United Kingdom
| | - Mark J. Dunne
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, United Kingdom
- *Correspondence: Mark J. Dunne
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Brown RE, Senniappan S, Hussain K, McGuire MF. Morphoproteomics and biomedical analytics coincide with clinical outcomes in supporting a constant but variable role for the mTOR pathway in the biology of congenital hyperinsulinism of infancy. Orphanet J Rare Dis 2017; 12:181. [PMID: 29246172 PMCID: PMC5732475 DOI: 10.1186/s13023-017-0735-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 12/06/2017] [Indexed: 11/10/2022] Open
Abstract
We first introduced the concept of the mTOR pathway’s involvement in congenital hyperinsulinism of infancy (CHI), based largely on morphoproteomic observations and clinical outcomes using sirolimus (rapamycin) as a therapeutic agent in infants refractory to octreotide and diazoxide treatment. Subsequent publications have verified the efficacy of such treatment in some cases but limited and variable in others. We present further evidence of a constant but variable role for the mTOR pathway in the biology of CHI and provide a strategy that allows for the short-term testing of sirolimus in individual CHI patients.
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Affiliation(s)
- Robert E Brown
- Department of Pathology and Laboratory Medicine, UT Health McGovern Medical School, Houston, TX, USA.
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, L12 2AP, UK
| | - Khalid Hussain
- Department of Paediatric Medicine Division of Endocrinology, Sidra Medical & Research Center OPC, C6-337, PO Box 26999, Doha, Qatar
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21
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Abstract
Pancreatic β-cells are finely tuned to secrete insulin so that plasma glucose levels are maintained within a narrow physiological range (3.5-5.5 mmol/L). Hyperinsulinaemic hypoglycaemia (HH) is the inappropriate secretion of insulin in the presence of low plasma glucose levels and leads to severe and persistent hypoglycaemia in neonates and children. Mutations in 12 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1 and PMM2) that are involved in the regulation of insulin secretion from pancreatic β-cells have been described to be responsible for the underlying molecular mechanisms leading to congenital HH. In HH due to the inhibitory effect of insulin on lipolysis and ketogenesis there is suppressed ketone body formation in the presence of hypoglycaemia thus leading to increased risk of hypoglycaemic brain injury. Therefore, a prompt diagnosis and immediate management of HH is essential to avoid hypoglycaemic brain injury and long-term neurological complications in children. Advances in molecular genetics, imaging techniques (18F-DOPA positron emission tomography/computed tomography scanning), medical therapy and surgical advances (laparoscopic and open pancreatectomy) have changed the management and improved the outcome of patients with HH. This review article provides an overview to the background, clinical presentation, diagnosis, molecular genetics and therapy in children with different forms of HH.
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Affiliation(s)
- Hüseyin Demirbilek
- Hacettepe University Faculty of Medicine, Department of Paediatric Endocrinology, Ankara, Turkey
| | - Khalid Hussain
- Sidra Medical and Research Center, Clinic of Paediatric Medicine, Doha, Qatar
,* Address for Correspondence: Sidra Medical and Research Center, Clinic of Paediatric Medicine, Doha, Qatar Phone: +974-30322007 E-mail:
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22
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Abstract
Congenital hyperinsulinism is a rare disorder that commonly presents in the immediate postnatal period as persistent hypoglycemia. The condition is frequently resistant to medical therapies, and the genetic mutations implicated in the disorder can be predictive of response to therapy. Evaluation of hypoglycemia in the illustrative case presented in this article led to genetic testing identifying recessive mutations in the potassium channel subunits of the beta-islet pancreatic cells. Potassium channel defects are often refractory to medical therapies, so near-total pancreatectomy is usually indicated; however, genetic mutations leading to metabolic dysregulation within the beta-islet pancreatic cells are usually responsive to medical therapy. Aggressive treatment of hypoglycemia in the setting of congenital hyperinsulinism is important to prevent long-term neurologic sequelae secondary to hypoglycemia-induced brain injury. [Pediatr Ann. 2017;46(11):e409-e414.].
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23
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Han B, Mohamed Z, Estebanez MS, Craigie RJ, Newbould M, Cheesman E, Padidela R, Skae M, Johnson M, Flanagan S, Ellard S, Cosgrove KE, Banerjee I, Dunne MJ. Atypical Forms of Congenital Hyperinsulinism in Infancy Are Associated With Mosaic Patterns of Immature Islet Cells. J Clin Endocrinol Metab 2017; 102:3261-3267. [PMID: 28605545 PMCID: PMC5587070 DOI: 10.1210/jc.2017-00158] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 06/02/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVES We aimed to characterize mosaic populations of pancreatic islet cells from patients with atypical congenital hyperinsulinism in infancy (CHI-A) and the expression profile of NKX2.2, a key transcription factor expressed in β-cells but suppressed in δ-cells in the mature pancreas. PATIENTS/METHODS Tissue was isolated from three patients with CHI-A following subtotal pancreatectomy. CHI-A was diagnosed on the basis of islet mosaicism and the absence of histopathological hallmarks of focal and diffuse CHI (CHI-D). Immunohistochemistry was used to identify and quantify the proportions of insulin-secreting β-cells and somatostatin-secreting δ-cells in atypical islets, and results were compared with CHI-D (n = 3) and age-matched control tissues (n = 3). RESULTS In CHI-A tissue, islets had a heterogeneous profile. In resting/quiescent islets, identified by a condensed cytoplasm and nuclear crowding, β-cells were reduced to <50% of the total cell numbers in n = 65/70 islets, whereas δ-cell numbers were increased with 85% of islets (n = 49/57) containing >20% δ-cells. In comparison, all islets in control tissue (n = 72) and 99% of CHI-D islets (n = 72) were composed of >50% β-cells, and >20% δ-cells were found only in 12% of CHI-D (n = 8/66) and 5% of control islets (n = 3/60). Active islets in CHI-A tissue contained proportions of β-cells and δ-cells similar to those of control and CHI-D islets. Finally, when compared with active islets, quiescent islets had a twofold higher prevalence of somatostatin/NKX2.2+ coexpressed cells. CONCLUSIONS Marked increases in NKX2.2 expression combined with increased numbers of δ-cells strongly imply that an immature δ-cell profile contributed to the pathobiology of CHI-A.
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Affiliation(s)
- Bing Han
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Zainab Mohamed
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, United Kingdom
- Paediatric Endocrinology, The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Maria Salomon Estebanez
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, United Kingdom
- Paediatric Endocrinology, The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Ross J. Craigie
- Paediatric Surgery, Central Manchester University Hospitals NHS Foundation Trust (CMFT) and The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Melanie Newbould
- Paediatric Histopathology, Central Manchester University Hospitals NHS Foundation Trust (CMFT) and The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Edmund Cheesman
- Paediatric Histopathology, Central Manchester University Hospitals NHS Foundation Trust (CMFT) and The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Raja Padidela
- Paediatric Endocrinology, The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Mars Skae
- Paediatric Endocrinology, The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Matthew Johnson
- Molecular Genetics, Royal Devon and Exeter NHS Foundation Trust, University of Exeter Medical School, Royal Devon and Exeter Hospital, Exeter EX2 5DW, United Kingdom
| | - Sarah Flanagan
- Molecular Genetics, Royal Devon and Exeter NHS Foundation Trust, University of Exeter Medical School, Royal Devon and Exeter Hospital, Exeter EX2 5DW, United Kingdom
| | - Sian Ellard
- Molecular Genetics, Royal Devon and Exeter NHS Foundation Trust, University of Exeter Medical School, Royal Devon and Exeter Hospital, Exeter EX2 5DW, United Kingdom
| | - Karen E. Cosgrove
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Indraneel Banerjee
- Paediatric Endocrinology, The University of Manchester, Manchester M13 9PT, United Kingdom
| | - Mark J. Dunne
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M13 9PT, United Kingdom
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24
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Demirbilek H, Rahman SA, Buyukyilmaz GG, Hussain K. Diagnosis and treatment of hyperinsulinaemic hypoglycaemia and its implications for paediatric endocrinology. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2017; 2017:9. [PMID: 28855921 PMCID: PMC5575922 DOI: 10.1186/s13633-017-0048-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/15/2017] [Indexed: 12/14/2022]
Abstract
Glucose homeostasis requires appropriate and synchronous coordination of metabolic events and hormonal activities to keep plasma glucose concentrations in a narrow range of 3.5–5.5 mmol/L. Insulin, the only glucose lowering hormone secreted from pancreatic β-cells, plays the key role in glucose homeostasis. Insulin release from pancreatic β-cells is mainly regulated by intracellular ATP-generating metabolic pathways. Hyperinsulinaemic hypoglycaemia (HH), the most common cause of severe and persistent hypoglycaemia in neonates and children, is the inappropriate secretion of insulin which occurs despite low plasma glucose levels leading to severe and persistent hypoketotic hypoglycaemia. Mutations in 12 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1 and PMM2) constitute the underlying molecular mechanisms of congenital HH. Since insulin supressess ketogenesis, the alternative energy source to the brain, a prompt diagnosis and immediate management of HH is essential to avoid irreversible hypoglycaemic brain damage in children. Advances in molecular genetics, imaging methods (18F–DOPA PET-CT), medical therapy and surgical approach (laparoscopic and open pancreatectomy) have changed the management and improved the outcome of patients with HH. This up to date review article provides a background to the diagnosis, molecular genetics, recent advances and therapeutic options in the field of HH in children.
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Affiliation(s)
- Huseyin Demirbilek
- Department of Paediatric Endocrinology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Sofia A Rahman
- Great Ormond Street Institute of Child Health, Genetics and Genomic Medicine, University College London, 30 Guilford Street, London, WC1N 1EH UK
| | - Gonul Gulal Buyukyilmaz
- Department of Paediatric Endocrinology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Khalid Hussain
- Department of Paediatric Medicine Sidra Medical & Research Center, OPC, C6-337, PO Box 26999, Doha, Qatar
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25
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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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26
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Li C, Ackermann AM, Boodhansingh KE, Bhatti TR, Liu C, Schug J, Doliba N, Han B, Cosgrove KE, Banerjee I, Matschinsky FM, Nissim I, Kaestner KH, Naji A, Adzick NS, Dunne MJ, Stanley CA, De León DD. Functional and Metabolomic Consequences of K ATP Channel Inactivation in Human Islets. Diabetes 2017; 66:1901-1913. [PMID: 28442472 PMCID: PMC5482088 DOI: 10.2337/db17-0029] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 04/15/2017] [Indexed: 12/17/2022]
Abstract
Loss-of-function mutations of β-cell KATP channels cause the most severe form of congenital hyperinsulinism (KATPHI). KATPHI is characterized by fasting and protein-induced hypoglycemia that is unresponsive to medical therapy. For a better understanding of the pathophysiology of KATPHI, we examined cytosolic calcium ([Ca2+] i ), insulin secretion, oxygen consumption, and [U-13C]glucose metabolism in islets isolated from the pancreases of children with KATPHI who required pancreatectomy. Basal [Ca2+] i and insulin secretion were higher in KATPHI islets compared with controls. Unlike controls, insulin secretion in KATPHI islets increased in response to amino acids but not to glucose. KATPHI islets have an increased basal rate of oxygen consumption and mitochondrial mass. [U-13C]glucose metabolism showed a twofold increase in alanine levels and sixfold increase in 13C enrichment of alanine in KATPHI islets, suggesting increased rates of glycolysis. KATPHI islets also exhibited increased serine/glycine and glutamine biosynthesis. In contrast, KATPHI islets had low γ-aminobutyric acid (GABA) levels and lacked 13C incorporation into GABA in response to glucose stimulation. The expression of key genes involved in these metabolic pathways was significantly different in KATPHI β-cells compared with control, providing a mechanism for the observed changes. These findings demonstrate that the pathophysiology of KATPHI is complex, and they provide a framework for the identification of new potential therapeutic targets for this devastating condition.
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Affiliation(s)
- Changhong Li
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Amanda M Ackermann
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kara E Boodhansingh
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tricia R Bhatti
- Department of Pathology, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chengyang Liu
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Schug
- Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nicolai Doliba
- Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bing Han
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
| | - Karen E Cosgrove
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
| | - Indraneel Banerjee
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
| | - Franz M Matschinsky
- Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Itzhak Nissim
- Division of Metabolism, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Klaus H Kaestner
- Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ali Naji
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - N Scott Adzick
- Department of Surgery, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark J Dunne
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
| | - Charles A Stanley
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Diva D De León
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Institute for Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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27
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Cross SE, Vaughan RH, Willcox AJ, McBride AJ, Abraham AA, Han B, Johnson JD, Maillard E, Bateman PA, Ramracheya RD, Rorsman P, Kadler KE, Dunne MJ, Hughes SJ, Johnson PRV. Key Matrix Proteins Within the Pancreatic Islet Basement Membrane Are Differentially Digested During Human Islet Isolation. Am J Transplant 2017; 17:451-461. [PMID: 27456745 DOI: 10.1111/ajt.13975] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 07/12/2016] [Indexed: 02/06/2023]
Abstract
Clinical islet transplantation achieves insulin independence in selected patients, yet current methods for extracting islets from their surrounding pancreatic matrix are suboptimal. The islet basement membrane (BM) influences islet function and survival and is a critical marker of islet integrity following rodent islet isolation. No studies have investigated the impact of islet isolation on BM integrity in human islets, which have a unique duplex structure. To address this, samples were taken from 27 clinical human islet isolations (donor age 41-59, BMI 26-38, cold ischemic time < 10 h). Collagen IV, pan-laminin, perlecan and laminin-α5 in the islet BM were significantly digested by enzyme treatment. In isolated islets, laminin-α5 (found in both layers of the duplex BM) and perlecan were lost entirely, with no restoration evident during culture. Collagen IV and pan-laminin were present in the disorganized BM of isolated islets, yet a significant reduction in pan-laminin was seen during the initial 24 h culture period. Islet cytotoxicity increased during culture. Therefore, the human islet BM is substantially disrupted during the islet isolation procedure. Islet function and survival may be compromised as a consequence of an incomplete islet BM, which has implications for islet survival and transplanted graft longevity.
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Affiliation(s)
- S E Cross
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - R H Vaughan
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - A J Willcox
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - A J McBride
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - A A Abraham
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - B Han
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - J D Johnson
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - E Maillard
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - P A Bateman
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - R D Ramracheya
- Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - P Rorsman
- Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - K E Kadler
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - M J Dunne
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - S J Hughes
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
| | - P R V Johnson
- Islet Transplant Research Group, Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, University of Oxford, Oxford, UK
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28
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Salomon-Estebanez M, Flanagan SE, Ellard S, Rigby L, Bowden L, Mohamed Z, Nicholson J, Skae M, Hall C, Craigie R, Padidela R, Murphy N, Randell T, Cosgrove KE, Dunne MJ, Banerjee I. Conservatively treated Congenital Hyperinsulinism (CHI) due to K-ATP channel gene mutations: reducing severity over time. Orphanet J Rare Dis 2016; 11:163. [PMID: 27908292 PMCID: PMC5133749 DOI: 10.1186/s13023-016-0547-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 11/22/2016] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Patients with Congenital Hyperinsulinism (CHI) due to mutations in K-ATP channel genes (K-ATP CHI) are increasingly treated by conservative medical therapy without pancreatic surgery. However, the natural history of medically treated K-ATP CHI has not been described; it is unclear if the severity of recessively and dominantly inherited K-ATP CHI reduces over time. We aimed to review variation in severity and outcomes in patients with K-ATP CHI treated by medical therapy. METHODS Twenty-one consecutively presenting patients with K-ATP CHI with dominantly and recessively inherited mutations in ABCC8/KCNJ11 were selected in a specialised CHI treatment centre to review treatment outcomes. Medical treatment included diazoxide and somatostatin receptor agonists (SSRA), octreotide and somatuline autogel. CHI severity was assessed by glucose infusion rate (GIR), medication dosage and tendency to resolution. CHI outcome was assessed by glycaemic profile, fasting tolerance and neurodevelopment. RESULTS CHI presenting at median (range) age 1 (1, 240) days resolved in 15 (71%) patients at age 3.1(0.2, 13.0) years. Resolution was achieved both in patients responsive to diazoxide (n = 8, 57%) and patients responsive to SSRA (n = 7, 100%) with earlier resolution in the former [1.6 (0.2, 13.0) v 5.9 (1.6, 9.0) years, p = 0.08]. In 6 patients remaining on treatment, diazoxide dose was reduced in follow up [10.0 (8.5, 15.0) to 5.4 (0.5, 10.8) mg/kg/day, p = 0.003]. GIR at presentation did not correlate with resolved or persistent CHI [14.9 (10.0, 18.5) v 16.5 (13.0, 20.0) mg/kg/min, p = 0.6]. The type of gene mutation did not predict persistence; resolution could be achieved in recessively-inherited CHI with homozygous (n = 3), compound heterozygous (n = 2) and paternal mutations causing focal CHI (n = 2). Mild developmental delay was present in 8 (38%) patients; adaptive functioning assessed by Vineland Adaptive Behavior Scales questionnaire showed a trend towards higher standard deviation scores (SDS) in resolved than persistent CHI [-0.1 (-1.2, 1.6) v -1.2 (-1.7, 0.03), p = 0.1]. CONCLUSIONS In K-ATP CHI patients managed by medical treatment only, severity is reduced over time in the majority, including those with compound heterozygous and homozygous mutations in ABCC8/KCNJ11. Severity and treatment requirement should be assessed periodically in all children with K-ATP CHI on medical therapy.
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Affiliation(s)
- Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK. .,Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, RILD Building, RD&E Hospital Wonford, Barrack Road, Exeter, EX2 5DW, UK
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, RILD Building, RD&E Hospital Wonford, Barrack Road, Exeter, EX2 5DW, UK
| | - Lindsey Rigby
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Louise Bowden
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Zainab Mohamed
- Department of Paediatric Endocrinology and Diabetes, Nottingham Children's Hospital, Nottingham University Hospitals, Derby Road, Nottingham, NG7 2UH, UK
| | - Jacqueline Nicholson
- Paediatric Psychosocial Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Mars Skae
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Caroline Hall
- Therapy and Dietetic Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Ross Craigie
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Nuala Murphy
- Department of Diabetes and Endocrinology, Children's University Hospital, Temple Street, Dublin, Ireland
| | - Tabitha Randell
- Department of Paediatric Endocrinology and Diabetes, Nottingham Children's Hospital, Nottingham University Hospitals, Derby Road, Nottingham, NG7 2UH, UK
| | - Karen E Cosgrove
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK
| | - Mark J Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK.,Faculty of Biology, Medicine and Health, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK
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