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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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2
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Hyperinsulinism. ENDOCRINES 2022. [DOI: 10.3390/endocrines3010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Congenital or monogenic hyperinsulinism (HI) is a group of rare genetic disorders characterized by dysregulated insulin secretion and is the most common cause of persistent hypoglycemia in children. Knowledge of normal glucose homeostasis allows for a better understanding of the underlying pathophysiology of hyperinsulinemic hypoglycemia, facilitating timely diagnosis and management. The goal of management is to prevent cerebral insults secondary to hypoglycemia, which can result in poor neurologic outcomes and intellectual disability. Responsiveness to diazoxide, the first-line pharmacologic therapy for persistent hypoglycemia, is also the first step to distinguishing the different genotypic causes of monogenic hyperinsulinism. Early genetic testing becomes necessary when monogenic HI is strongly considered. Knowledge of specific gene mutations allows the determination of a clinical prognosis and definite therapeutic options, such as identifying those with focal forms of hyperinsulinism, who may attain a complete cure through surgical removal of specific affected parts of the pancreas. However, the lack of identifiable cause in a considerable number of patients identified with HI suggests there may be other genetic loci that are yet to be discovered. Furthermore, continued research is needed to explore new forms of therapy, particularly in severe, diazoxide-nonresponsive cases.
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3
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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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Wieland I, Schanze I, Felgendreher IM, Barthlen W, Vogelgesang S, Mohnike K, Zenker M. Integration of genomic analysis and transcript expression of ABCC8 and KCNJ11 in focal form of congenital hyperinsulinism. Front Endocrinol (Lausanne) 2022; 13:1015244. [PMID: 36339418 PMCID: PMC9634566 DOI: 10.3389/fendo.2022.1015244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/03/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The focal form of CHI is caused by an autosomal recessive pathogenic variant affecting the paternal homologue of genes ABCC8 or KCNJ11 and a second somatic event specifically occurring in the affected islet of Langerhans. The approach of this study was to integrate the genetic changes occurring in pancreatic focal lesions of CHI at the genomic and transcriptional level. RESEARCH DESIGN AND METHODS Patients receiving therapeutic surgery and with proven ABCC8 or KCNJ11 pathogenic variants were selected and analyzed for loss of heterozygosity (LOH), changes in copy number and uniparental disomy (UPD) on the short am of chromosome 11 by molecular microarray analysis and methylation-specific MLPA. Gene expression was analyzed by RT-PCR and Massive Analysis of cDNA Ends (MACE). RESULTS Both genes, ABCC8 and KCNJ11, are located in proximity to the Beckwith-Wiedemann (BWS) imprinting control region on chromosome 11p15. Somatic paternal uniparental isodisomy (UPD) at chromosome 11p was identified as second genetic event in focal lesions resulting in LOH and monoallelic expression of the mutated ABCC8/KCNJ11 alleles. Of five patients with samples available for microarray analysis, the breakpoints of UPD on chromosome 11p were different. Samples of two patients were analyzed further for changes in gene expression. Profound downregulation of growth suppressing genes CDKN1 and H19 was detected in focal lesions whereas growth promoting gene ASCL2 and pancreatic transcription factors of the endocrine cell lineage were upregulated. CONCLUSIONS Paternal UPD on the short arm of chromosome 11 appears to be the major second genetic event specifically within focal lesions of CHI but no common breakpoint for UDP can be delineated. We show for the first time upregulation of growth promoting ASCL2 (achaete-scute homolog 2) suggestive of a driving factor in postnatal focal expansion in addition to downregulation of growth suppressing genes CDKN1C and H19.
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Affiliation(s)
- Ilse Wieland
- Institute of Human Genetics, University Hospital Otto-von-Guericke- University Magdeburg, Magdeburg, Germany
- *Correspondence: Ilse Wieland,
| | - Ina Schanze
- Institute of Human Genetics, University Hospital Otto-von-Guericke- University Magdeburg, Magdeburg, Germany
| | - Ina Marianti Felgendreher
- Institute of Human Genetics, University Hospital Otto-von-Guericke- University Magdeburg, Magdeburg, Germany
| | - Winfried Barthlen
- Department of Pediatric Surgery, Protestant Hospital of Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
| | - Silke Vogelgesang
- University Medicine, Institute of Pathology, University of Greifswald, Greifswald, Germany
| | - Klaus Mohnike
- Dept of Pediatrics, University Hospital Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Martin Zenker
- Institute of Human Genetics, University Hospital Otto-von-Guericke- University Magdeburg, Magdeburg, Germany
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Kostopoulou E, Dastamani A, Güemes M, Clement E, Caiulo S, Shanmugananda P, Dattani M, Gilbert C, Hurst JA, Shah P. Syndromic Forms of Hyperinsulinaemic Hypoglycaemia-A 15-year follow-up Study. Clin Endocrinol (Oxf) 2021; 94:399-412. [PMID: 33345357 DOI: 10.1111/cen.14393] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 10/18/2020] [Accepted: 11/24/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Hyperinsulinaemic hypoglycaemia (HH) is one of the commonest causes of hypoglycaemia in children. The molecular basis includes defects in pathways that regulate insulin release. Syndromic conditions like Beckwith-Wiedemann (BWS), Kabuki (KS) and Turner (TS) are known to be associated with a higher risk for HH. This systematic review of children with HH referred to a tertiary centre aims at estimating the frequency of a syndromic/multisystem condition to help address stratification of genetic analysis in infants with HH. METHODS We performed a retrospective study of 69 patients with syndromic features and hypoglycaemia in a specialist centre from 2004 to 2018. RESULTS Biochemical investigations confirmed HH in all the cases and several genetic diagnoses were established. Responsiveness to medications and the final outcome following medical treatment or surgery were studied. CONCLUSIONS This study highlights the association of HH with a wide spectrum of syndromic diagnoses and that children with features suggestive of HH-associated syndromes should be monitored for hypoglycaemia. If hypoglycaemia is documented, they should also be screened for possible HH. Our data indicate that most syndromic forms of HH are diazoxide-responsive and that HH resolves over time; however, a significant percentage continues to require medications years after the onset of the disease. Early diagnosis of hyperinsulinism and initiation of treatment is important for preventing hypoglycaemic brain injury and intellectual disability.
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Affiliation(s)
- Eirini Kostopoulou
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Antonia Dastamani
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Maria Güemes
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Program, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Emma Clement
- Department of Genetics, Great Ormond Street Hospital for Children, London, UK
| | - Silvana Caiulo
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Prateek Shanmugananda
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Mehul Dattani
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Program, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Clare Gilbert
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Jane A Hurst
- Department of Genetics, Great Ormond Street Hospital for Children, London, UK
| | - Pratik Shah
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Program, UCL Great Ormond Street Institute of Child Health, London, UK
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Gϋemes M, Rahman SA, Kapoor RR, Flanagan S, Houghton JAL, Misra S, Oliver N, Dattani MT, Shah P. Hyperinsulinemic hypoglycemia in children and adolescents: Recent advances in understanding of pathophysiology and management. Rev Endocr Metab Disord 2020; 21:577-597. [PMID: 32185602 PMCID: PMC7560934 DOI: 10.1007/s11154-020-09548-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hyperinsulinemic hypoglycemia (HH) is characterized by unregulated insulin release, leading to persistently low blood glucose concentrations with lack of alternative fuels, which increases the risk of neurological damage in these patients. It is the most common cause of persistent and recurrent hypoglycemia in the neonatal period. HH may be primary, Congenital HH (CHH), when it is associated with variants in a number of genes implicated in pancreatic development and function. Alterations in fifteen genes have been recognized to date, being some of the most recently identified mutations in genes HK1, PGM1, PMM2, CACNA1D, FOXA2 and EIF2S3. Alternatively, HH can be secondary when associated with syndromes, intra-uterine growth restriction, maternal diabetes, birth asphyxia, following gastrointestinal surgery, amongst other causes. CHH can be histologically characterized into three groups: diffuse, focal or atypical. Diffuse and focal forms can be determined by scanning using fluorine-18 dihydroxyphenylalanine-positron emission tomography. Newer and improved isotopes are currently in development to provide increased diagnostic accuracy in identifying lesions and performing successful surgical resection with the ultimate aim of curing the condition. Rapid diagnostics and innovative methods of management, including a wider range of treatment options, have resulted in a reduction in co-morbidities associated with HH with improved quality of life and long-term outcomes. Potential future developments in the management of this condition as well as pathways to transition of the care of these highly vulnerable children into adulthood will also be discussed.
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Affiliation(s)
- Maria Gϋemes
- Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, WC1N 3JH, UK
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Endocrinology Service, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sofia Asim Rahman
- Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, WC1N 3JH, UK
| | - Ritika R Kapoor
- Pediatric Diabetes and Endocrinology, King's College Hospital NHS Trust, Denmark Hill, London, UK
| | - Sarah 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
- Royal Devon and Exeter Foundation Trust, Exeter, UK
| | - Shivani Misra
- Department of Diabetes, Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Nick Oliver
- Department of Diabetes, Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Mehul Tulsidas Dattani
- Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, WC1N 3JH, UK
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Pratik Shah
- Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, WC1N 3JH, UK.
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK.
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Yau D, Marwaha R, Mohnike K, Sajjan R, Empting S, Craigie RJ, Dunne MJ, Salomon-Estebanez M, Banerjee I. Case report: contradictory genetics and imaging in focal congenital hyperinsulinism reinforces the need for pancreatic biopsy. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2020; 2020:17. [PMID: 32874187 PMCID: PMC7457521 DOI: 10.1186/s13633-020-00086-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/31/2020] [Indexed: 12/02/2022]
Abstract
Background Congenital Hyperinsulinism (CHI) is an important cause of severe hypoglycaemia in infancy due to excessive, dysregulated insulin secretion. In focal CHI, a localised lesion within the pancreas hypersecretes insulin and, importantly, hypoglycaemia resolution is possible through limited surgical resection of the lesion. Diagnosis of focal CHI is based on a crucial combination of compatible genetics and specialised imaging. Specifically, a focal lesion arises due to a paternal mutation in one of the ATP-sensitive potassium channel genes, KCNJ11 or ABCC8, in combination with post-zygotic loss of maternal heterozygosity within the affected pancreatic tissue. 6-[18F]Fluoro-L-3,4-dihydroxyphenylalanine (18F-DOPA) positron emission tomography (PET)/computed tomography (CT) imaging is used to detect and localise the lesion prior to surgery. However, its accuracy is imperfect and needs recognition in individual case management. Case presentation We report the case of an infant with hypoglycaemia due to CHI and a paternally inherited KCNJ11 mutation, c.286G > A (p.Ala96Thr), leading to a high probability of focal CHI. However,18F-DOPA PET/CT scanning demonstrated diffuse uptake and failed to conclusively identify a focal lesion. Due to unresponsiveness to medical therapy and ongoing significant hypoglycaemia, surgery was undertaken and a small 4.9 × 1.7 mm focal lesion was discovered at the pancreatic neck. This is the second case where this particular KCNJ11 mutation has been incorrectly associated with diffuse 18F-DOPA uptake, in contrast to the correct diagnosis of focal CHI confirmed by pancreatic biopsy. Conclusions Identifying discrepancies between genetic and imaging investigations is crucial as this may negatively impact upon the diagnosis and surgical treatment of focal CHI. This case highlights the need for pancreatic biopsy when a strong suspicion of focal CHI is present even if 18F-DOPA imaging fails to demonstrate a discrete lesion.
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Affiliation(s)
- Daphne Yau
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, M13 9WL UK.,Department of Pediatrics, University of Saskatchewan, Royal University Hospital, 103 Hospital Drive, Saskatoon, Saskatchewan S7N 0W8 Canada
| | - Ria Marwaha
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, M13 9WL UK
| | - Klaus Mohnike
- Department of Paediatrics, Otto von Guericke University Magdeburg, 39106 Magdeburg, Germany
| | - Rakesh Sajjan
- Nuclear Medicine Centre, New Saint Mary's Hospital, Manchester University Foundation Trust, Manchester, M13 9WL UK
| | - Susann Empting
- Department of Paediatrics, Otto von Guericke University Magdeburg, 39106 Magdeburg, Germany
| | - Ross J Craigie
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, M13 9WL UK
| | - Mark J Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, M13 9PL UK
| | - Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, M13 9WL UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, M13 9WL UK
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8
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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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9
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Yau D, Colclough K, Natarajan A, Parikh R, Canham N, Didi M, Senniappan S, Banerjee I. Congenital hyperinsulinism due to mutations in HNF1A. Eur J Med Genet 2020; 63:103928. [PMID: 32325224 DOI: 10.1016/j.ejmg.2020.103928] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 03/04/2020] [Accepted: 04/11/2020] [Indexed: 12/27/2022]
Abstract
Congenital hyperinsulinism is a rare but significant cause of severe and persistent hypoglycaemia in infancy. Although a biphasic phenotype of congenital hyperinsulinism in infancy followed by Maturity-Onset Diabetes of the Young (MODY) in later life has been established for HNF4A, the existence of a similar phenotype for a related MODY gene, HNF1A, is less clear. We describe two cases of congenital hyperinsulinism in association with dominantly inherited variants in HNF1A. They presented in the early neonatal period with unequivocal biochemical evidence of congenital hyperinsulinism and persistence into childhood with ongoing need for medical therapy. Both cases inherited HNF1A variants from a parent with a diabetes phenotype consistent with MODY, without obesity, insulin resistance or other metabolic syndrome features. In the first case, a paternally inherited novel c.-230_-101del variant was found that deletes the minimal promoter region presumably required for HNF1A expression. In the second case, a maternally inherited missense variant (c.713G>T, p.(Arg238Met)) was identified. This variant is predicted to cause haploinsufficiency via aberrant splicing and has previously been associated with MODY but not congenital hyperinsulinism. Our cases further strengthen the evidence for HNF1A as a CHI-causing gene requiring long-term follow-up.
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Affiliation(s)
- Daphne Yau
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK.
| | - Kevin Colclough
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | | | - Ruchi Parikh
- Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | | | - Mohammed Didi
- Paediatric Endocrinology, Alder Hey Children's Hospital, Liverpool, UK
| | | | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
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10
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Worth C, Hall C, Wilson S, Gilligan N, O'Shea E, Salomon-Estebanez M, Dunne M, Banerjee I. Delayed Resolution of Feeding Problems in Patients With Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2020; 11:143. [PMID: 32256453 PMCID: PMC7093368 DOI: 10.3389/fendo.2020.00143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/02/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Congenital Hyperinsulinism (CHI) is the most common cause of recurrent and severe hypoglycaemia in childhood. Feeding problems occur frequently in severe CHI but long-term persistence and rates of resolution have not been described. Methods: All patients with CHI admitted to a specialist center during 2015-2016 were assessed for feeding problems at hospital admission and for three years following discharge, through a combination of specialist speech and language therapy review and parent-report at clinical contact. Results: Twenty-five patients (18% of all patients admitted) with CHI were prospectively identified to have feeding problems related to sucking (n = 6), swallowing (n = 2), vomiting (n = 20), and feed aversion (n = 17) at the time of diagnosis. Sixteen (64%) patients required feeding support by nasogastric/gastrostomy tubes at diagnosis; tube feeding reduced to 4 (16%) patients by one year and 3 (12%) patients by three years. Feed aversion resolved slowly with mean time to resolution of 240 days after discharge; in 15 patients followed up for three years, 6 (24%) continued to report aversion. The mean time (days) to resolution of feeding problems was lower in those who underwent lesionectomy (n = 4) than in those who did not (30 vs. 590, p = 0.009) and significance persisted after adjustment for associated factors (p = 0.015). Conclusion: Feeding problems, particularly feed aversion, are frequent in patients with CHI and require support over several years. By contrast, feeding problems resolve rapidly in patients with focal CHI undergoing curative lesionectomy, suggesting the association of feeding problems with hyperinsulinism.
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Affiliation(s)
- Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Caroline Hall
- Therapy and Dietetic Department, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Sarah Wilson
- Therapy and Dietetic Department, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Niamh Gilligan
- Therapy and Dietetic Department, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Elaine O'Shea
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Mark Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
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11
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Kostopoulou E, Shah P. Hyperinsulinaemic hypoglycaemia-an overview of a complex clinical condition. Eur J Pediatr 2019; 178:1151-1160. [PMID: 31243576 DOI: 10.1007/s00431-019-03414-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 12/18/2022]
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is a major cause of hypoglycaemia in the neonatal period, infancy and childhood. It is caused by unsuppressed insulin secretion in the setting of hypoglycaemia and carries a high risk of significant neurological sequelae, such as cognitive impairment. Genetic mutations have been implicated in the pathogenesis of the condition. Other causes include intra-uterine growth retardation, perinatal asphyxia, maternal diabetes mellitus and syndromes, such as Beckwith-Wiedemann. Based on the aetiology, the clinical presentation can range from absence of symptoms to the typical adrenergic symptoms and coma and even death. The diagnosis is based on biochemical findings and the gold-standard imaging technique is 18F-DOPA PET/CT scanning. Treatment options involve medications, such as diazoxide, nifedipine, glucagon and octreotide, as well as surgery. Novel treatment, such as long-acting octreotide, lanreotide and sirolimus, may be used as an alternative to pancreatectomy. Potential future medical treatments include exendin, a GLP-1 receptor antagonist, and glucagon infusion via a pump.Conclusion: Advances in the fields of genetic testing, imaging techniques and medical treatment are beginning to provide novel insights into earlier detection, less invasive treatment approaches and fewer complications associated with the complex entity of hyperinsulinaemic hypoglycaemia. What is Known: • HH is caused by dysregulated insulin release from the β cell due to genetic mutations and carries a risk for complications, such as neurocognitive impairment. 18F-DOPA PET/CT scanning is presented as the gold-standard imaging technique currently in children with hyperinsulinaemic hypoglycaemia. • Clinical presentation is heterogeneous and treatment options include medical therapy and pancreatectomy. What is New: • 18F-DOPA PET/CT is indicated in suspected focal CHI due to paternal transmitted mutations in ABCC8 or KCNJ11. • Novel treatment options have been introduced, such as long-acting octreotide, lanreotide, sirolimus and selective nonpeptide somatostatin receptor subtype 5 (SSTR5) agonists. Future medical treatments include exendin, a GLP-1 antagonist, and glucagon infusion via a pump. However, all these options are off-label at present.
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Affiliation(s)
- Eirini Kostopoulou
- Research Laboratory of the Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, School of Medicine, University of Patras, 26500, Patras, Greece.
| | - Pratik Shah
- Endocrinology Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
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12
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Yau D, Salomon-Estebanez M, Chinoy A, Grainger J, Craigie R, Padidela R, Skae M, Dunne M, Murray P, Banerjee I. Central venous catheter-associated thrombosis in children with congenital hyperinsulinism. Endocrinol Diabetes Metab Case Rep 2019; 2019. [PMID: 31373474 PMCID: PMC8115433 DOI: 10.1530/edm-19-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is an important cause of severe hypoglycaemia in infancy. To correct hypoglycaemia, high concentrations of dextrose are often required through a central venous catheter (CVC) with consequent risk of thrombosis. We describe a series of six cases of CHI due to varying aetiologies from our centre requiring CVC for the management of hypoglycaemia, who developed thrombosis in association with CVC. We subsequently analysed the incidence and risk factors for CVC-associated thrombosis, as well as the outcomes of enoxaparin prophylaxis. The six cases occurred over a 3-year period; we identified an additional 27 patients with CHI who required CVC insertion during this period (n = 33 total), and a separate cohort of patients with CHI and CVC who received enoxaparin prophylaxis (n = 7). The incidence of CVC-associated thrombosis was 18% (6/33) over the 3 years, a rate of 4.2 thromboses/1000 CVC days. There was no difference in the frequency of genetic mutations or focal CHI in those that developed thromboses. However, compound heterozygous/homozygous potassium ATP channel mutations correlated with thrombosis (R2 = 0.40, P = 0.001). No difference was observed in CVC duration, high concentration dextrose or glucagon infused through the CVC. In patients receiving enoxaparin prophylaxis, none developed thrombosis or bleeding complications. The characteristics of these patients did not differ significantly from those with thrombosis not on prophylaxis. We therefore conclude that CVC-associated thrombosis can occur in a significant proportion (18%) of patients with CHI, particularly in severe CHI, for which anticoagulant prophylaxis may be indicated.
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Affiliation(s)
- Daphne Yau
- Departments of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Maria Salomon-Estebanez
- Departments of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Amish Chinoy
- Departments of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - John Grainger
- Departments of Paediatric Haematology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Ross Craigie
- Departments of Paediatric Surgery, Royal Manchester Children’s Hospital, Manchester, UK
| | - Raja Padidela
- Departments of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Mars Skae
- Departments of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Mark Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Philip Murray
- Departments of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Indraneel Banerjee
- Departments of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
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13
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Galcheva S, Demirbilek H, Al-Khawaga S, Hussain K. The Genetic and Molecular Mechanisms of Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2019; 10:111. [PMID: 30873120 PMCID: PMC6401612 DOI: 10.3389/fendo.2019.00111] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/06/2019] [Indexed: 12/13/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a heterogenous and complex disorder in which the unregulated insulin secretion from pancreatic beta-cells leads to hyperinsulinaemic hypoglycaemia. The severity of hypoglycaemia varies depending on the underlying molecular mechanism and genetic defects. The genetic and molecular causes of CHI include defects in pivotal pathways regulating the secretion of insulin from the beta-cell. Broadly these genetic defects leading to unregulated insulin secretion can be grouped into four main categories. The first group consists of defects in the pancreatic KATP channel genes (ABCC8 and KCNJ11). The second and third categories of conditions are enzymatic defects (such as GDH, GCK, HADH) and defects in transcription factors (for example HNF1α, HNF4α) leading to changes in nutrient flux into metabolic pathways which converge on insulin secretion. Lastly, a large number of genetic syndromes are now linked to hyperinsulinaemic hypoglycaemia. As the molecular and genetic basis of CHI has expanded over the last few years, this review aims to provide an up-to-date knowledge on the genetic causes of CHI.
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Affiliation(s)
- Sonya Galcheva
- Department of Paediatrics, University Hospital St. Marina, Varna Medical University, Varna, Bulgaria
| | - Hüseyin Demirbilek
- Department of Paediatric Endocrinology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sara Al-Khawaga
- Division of Endocrinology, Department of Paediatric Medicine, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Division of Endocrinology, Department of Paediatric Medicine, Sidra Medicine, Doha, Qatar
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14
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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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15
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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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16
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Ludwig A, Enke S, Heindorf J, Empting S, Meissner T, Mohnike K. Formal Neurocognitive Testing in 60 Patients with Congenital Hyperinsulinism. Horm Res Paediatr 2018; 89:1-6. [PMID: 29151084 DOI: 10.1159/000481774] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 09/25/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) is hallmarked by persistent hypoketotic hypoglycemia in infancy. In the majority of all patients, CHI is caused by mutations in the KATP channel genes ABCC8 and KCNJ11, but other genes in the insulin-regulatory pathway have also been described. Repeated episodes of hypoglycemia include an increased risk of seizures and intellectual disability. So far, controlled psychometric studies on cognitive, motor, speech, and social-emotional outcome of CHI patients are missing. Until now, neurodevelopmental long-term outcome in CHI patients has only been measured by questionnaires, self-, parental-, or caregiver-administered instruments. METHODS This is a prospective study of 60 patients (median age 3.3 years, range 3 months to 57 years): 48 with a diffuse, 9 with a focal, and 3 with an atypical histology. Neurodevelopmental outcome was assessed using standardized psychological tests and questionnaires. RESULTS 28 of 60 patients showed developmental delay (46.7%). 9 of 57 patients had cognitive deficits (15.8%), 7 of 26 patients had speech problems (26.9%), and 17 of 44 patients had motor problems (38.6%). In 5 of 53 patients, social-emotional problems were reported. Outcome and the underlying genetic defect were not correlated. CONCLUSIONS Motor problems seem to be prominent in CHI patients. Despite a high incidence of developmental delay, a permanent cognitive defect was only detectable in 9 of 58 patients.
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Affiliation(s)
- Anja Ludwig
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Simone Enke
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Janine Heindorf
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Susann Empting
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Thomas Meissner
- Department of Pediatrics, University Duesseldorf, Duesseldorf, Germany
| | - Klaus Mohnike
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
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17
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Innaurato S, Brierley GV, Grasso V, Massimi A, Gaudino R, Sileno S, Bernardini S, Semple R, Barbetti F. Severe insulin resistance in disguise: A familial case of reactive hypoglycemia associated with a novel heterozygous INSR mutation. Pediatr Diabetes 2018; 19:670-674. [PMID: 29411486 DOI: 10.1111/pedi.12632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 12/06/2017] [Indexed: 01/23/2023] Open
Abstract
AIM Hypoglycemia in childhood is very rare and can be caused by genetic mutations or insulin-secreting neoplasms. Postprandial hypoglycemia has previously been associated with insulin receptor (INSR) gene mutations. We aimed to identify the cause of postprandial hypoglycemia in a 10-year-old boy. SUBJECTS We studied the symptomatic proband and his apparently asymptomatic mother and elder brother. All of them were lean. METHODS Metabolic screening of the proband included a 5-hour oral glucose tolerance test (OGTT), angio-magnetic resonance imaging, and 18 F-dihydroxyphenylalanine positron emission tomography/computed tomography imaging of the pancreas. INSR gene sequencing and in vitro functional studies of a novel INSR mutation were also undertaken. RESULTS Fasting hyperinsulinemia was detected during metabolic screening, and 5-hour OGTT showed hypoglycemia at 240' in the proband, his mother, and brother. Pancreatic imaging showed no evidence of neoplasia. Acanthosis nigricans with high fasting insulin levels in the proband suggested severe insulin resistance and prompted INSR gene sequencing, which revealed the novel, heterozygous p.Phe1213Leu mutation in the patient and his family members. In vitro studies showed that this mutation severely impairs insulin receptor function by abolishing tyrosine kinase activity and downstream insulin signaling. CONCLUSIONS The identification of etiological cause of hypoglycemia in childhood may be challenging. The combination of fasting hyperinsulinemia with acanthosis nigricans in a lean subject with hypoglycemia suggests severe insulin resistance and warrants INSR gene screening.
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Affiliation(s)
| | - Gemma V Brierley
- The University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK.,The National Institute for Health Research, Cambridge Biomedical Research Centre, Cambridge, UK
| | - Valeria Grasso
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Arianna Massimi
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Rossella Gaudino
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, University of Verona, Borgo Trento Hospital, Verona, Italy
| | - Sara Sileno
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Sergio Bernardini
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy
| | - Robert Semple
- The University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK.,The National Institute for Health Research, Cambridge Biomedical Research Centre, Cambridge, UK
| | - Fabrizio Barbetti
- Department of Experimental Medicine and Surgery, University of Rome Tor Vergata, Rome, Italy.,Bambino Gesù Children's Hospital, Rome, Italy
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18
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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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Yorifuji T, Horikawa R, Hasegawa T, Adachi M, Soneda S, Minagawa M, Ida S, Yonekura T, Kinoshita Y, Kanamori Y, Kitagawa H, Shinkai M, Sasaki H, Nio M. Clinical practice guidelines for congenital hyperinsulinism. Clin Pediatr Endocrinol 2017; 26:127-152. [PMID: 28804205 PMCID: PMC5537210 DOI: 10.1297/cpe.26.127] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/08/2017] [Indexed: 12/11/2022] Open
Abstract
Congenital hyperinsulinism is a rare condition, and following recent advances in
diagnosis and treatment, it was considered necessary to formulate evidence-based clinical
practice guidelines reflecting the most recent progress, to guide the practice of
neonatologists, pediatric endocrinologists, general pediatricians, and pediatric surgeons.
These guidelines cover a range of aspects, including general features of congenital
hyperinsulinism, diagnostic criteria and tools for diagnosis, first- and second-line
medical treatment, criteria for and details of surgical treatment, and future
perspectives. These guidelines were generated as a collaborative effort between The
Japanese Society for Pediatric Endocrinology and The Japanese Society of Pediatric
Surgeons, and followed the official procedures of guideline generation to identify
important clinical questions, perform a systematic literature review (April 2016), assess
the evidence level of each paper, formulate the guidelines, and obtain public
comments.
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Affiliation(s)
- Tohru Yorifuji
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | | | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Shun Soneda
- Department of Pediatrics, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | - Shinobu Ida
- Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Takeo Yonekura
- Department of Pediatric Surgery, Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Kanamori
- Department of Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Hideyuki Sasaki
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
| | - Masaki Nio
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
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Salomon-Estebanez M, Mohamed Z, Michaelidou M, Collins H, Rigby L, Skae M, Padidela R, Rust S, Dunne M, Cosgrove K, Banerjee I, Nicholson J. Vineland adaptive behavior scales to identify neurodevelopmental problems in children with Congenital Hyperinsulinism (CHI). Orphanet J Rare Dis 2017; 12:96. [PMID: 28532504 PMCID: PMC5440988 DOI: 10.1186/s13023-017-0648-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/09/2017] [Indexed: 11/25/2022] Open
Abstract
Background Congenital Hyperinsulinism (CHI) is a disease of severe hypoglycaemia caused by excess insulin secretion and associated with adverse neurodevelopment in a third of children. The Vineland Adaptive Behavior Scales Second Edition (VABS-II) is a parent report measure of adaptive functioning that could be used as a developmental screening tool in patients with CHI. We have investigated the performance of VABS-II as a screening tool to identify developmental delay in a relatively large cohort of children with CHI. VABS-II questionnaires testing communication, daily living skills, social skills, motor skills and behaviour domains were completed by parents of 64 children with CHI, presenting both in the early neonatal period (Early-CHI, n = 48) and later in infancy (Late-CHI, n = 16). Individual and adaptive composite (Total) domain scores were converted to standard deviation scores (SDS). VABS-II scores were tested for correlation with objective developmental assessment reported separately by developmental paediatricians, clinical and educational psychologists. VABS-II scores were also investigated for correlation with the timing of hypoglycaemia, gender and phenotype of CHI. Results Median (range) total VABS-II SDS was low in CHI [-0.48 (-3.60, 4.00)] with scores < -2.0 SDS in 9 (12%) children. VABS-II Total scores correctly identified developmental delay diagnosed by objective assessment in the majority [odds ratio (OR) (95% confidence intervals, CI) 0.52 (0.38, 0.73), p < 0.001] with 95% specificity [area under curve (CI) 0.80 (0.68, 0.90), p < 0.001] for cut-off < -2.0 SDS, although with low sensitivity (26%). VABS-II Total scores were inversely correlated (adjusted R2 = 0.19, p = 0.001) with age at presentation (p = 0.024) and male gender (p = 0.036), males having lower scores than females in those with Late-CHI [-1.40 (-3.60, 0.87) v 0.20 (-1.07, 1.27), p = 0.014]. The presence of a genetic mutation representing severe CHI also predicted lower scores (R2 = 0.19, p = 0.039). Conclusions The parent report VABS-II is a reliable and specific tool to identify developmental delay in CHI patients. Male gender, later age at presentation and severity of disease are independent risk factors for lower VABS-II scores.
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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 Road, Manchester, M13 9PL, UK.
| | - Zainab Mohamed
- Department of Paediatric Endocrinology and Diabetes, Nottingham Children's Hospital, Nottingham University Hospitals, Derby Road, Nottingham, NG7 2UH, UK
| | - Maria Michaelidou
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Hannah Collins
- Paediatric Psychosocial Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Lindsey Rigby
- Department of Paediatric Endocrinology, 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
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Stewart Rust
- Paediatric Psychosocial Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
| | - Mark Dunne
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Karen Cosgrove
- Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, 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 Road, Manchester, M13 9PL, UK
| | - Jacqueline Nicholson
- Paediatric Psychosocial Department, Royal Manchester Children's Hospital, Central Manchester University Hospitals, Oxford Road, Manchester, M13 9WL, UK
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21
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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: 41] [Impact Index Per Article: 5.1] [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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22
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Banerjee I, Forsythe L, Skae M, Avatapalle HB, Rigby L, Bowden LE, Craigie R, Padidela R, Ehtisham S, Patel L, Cosgrove KE, Dunne MJ, Clayton PE. Feeding Problems Are Persistent in Children with Severe Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2016; 7:8. [PMID: 26903946 PMCID: PMC4747152 DOI: 10.3389/fendo.2016.00008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 01/18/2016] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) is a rare but severe disorder of hypoglycemia in children, often complicated by brain injury. In CHI, the long-term prevention of hypoglycemia is dependent on reliable enteral intake of glucose. However, feeding problems (FPs) often impede oral glucose delivery, thereby complicating the management of hypoglycemia. FPs have not been systematically characterized in follow-up in a cohort with CHI. AIMS We aimed to determine the prevalence, types, and persistence of FPs in a cohort of children with CHI and investigate potential causal factors. METHODS FPs were defined as difficulty with sucking, swallowing, vomiting, and food refusal (or a combination) in an observational study in 83 children in a specialized CHI treatment center. The prevalence of FPs at diagnosis, 6, and 12 months after diagnosis were noted. Genetic mutation status and markers of severity of CHI were tested for association with FPs. RESULTS A third of children with CHI had FPs (n = 28), of whom 93% required antireflux medication and 75% required nasogastric and gastrostomy tube feeding. Sucking and swallowing problems were present at diagnosis but absent later. Vomiting was present in 54% at 6 months, while food refusal was present in 68% at 6 months and 52% at 12 months. The age at commencing and stopping nasogastric tube feeding did not correlate with FPs frequency at 6 and 12 months. Children with FPs had severe hypoglycemia at diagnosis and required glucagon infusion more often [odds ratio (OR) (95% confidence intervals) (95% CI) 28.13 (2.6-300.1), p = 0.006] to normalize glucose levels. FPs were more frequent in those with diffuse CHI undergoing subtotal pancreatectomy [n (%) = 10 (35%) vs. 0 (0%), p < 0.001], in contrast to those with spontaneous resolution [6 (22%) vs. 32 (58%), p = 0.002]. Those undergoing focal lesionectomy also had reduced FPs at 6 months after diagnosis [OR (95% CI) 0.01 (0.0-0.2), R (2) = 0.42, p = 0.004]. These observations suggest that persistence of hyperinsulinism was associated with FPs. CONCLUSION FPs occur in a significant proportion of children with CHI. Severe hyperinsulinism, rather than nasogastric tube feeding or medications, is the main factor associated with FPs.
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Affiliation(s)
- Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Lynette Forsythe
- Department of Dietetics and Nutrition, Royal Manchester Children’s Hospital, Manchester, UK
| | - Mars Skae
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Hima Bindu Avatapalle
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Lindsey Rigby
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Louise E. Bowden
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Ross Craigie
- Department of Paediatric Surgery, Royal Manchester Children’s Hospital, Manchester, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Sarah Ehtisham
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Leena Patel
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
| | | | - Mark J. Dunne
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Peter E. Clayton
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, UK
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
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23
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Biomarkers of Insulin for the Diagnosis of Hyperinsulinemic Hypoglycemia in Infants and Children. J Pediatr 2016; 168:212-219. [PMID: 26490124 DOI: 10.1016/j.jpeds.2015.09.045] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 08/07/2015] [Accepted: 09/11/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate thresholds of various biomarkers for defining excess insulin activity to recognize congenital hyperinsulinism. STUDY DESIGN This was a retrospective chart review of diagnostic fasting tests in children with ketotic hypoglycemia (n = 30) and genetically/pathology confirmed congenital hyperinsulinism (n = 28). Sensitivity and specificity for congenital hyperinsulinism were determined for plasma insulin, β-hydroxybutyrate, free fatty acids (FFA), C-peptide, insulin-like growth factor binding protein-1 (IGFBP-1), and the glycemic response to glucagon (through the glucagon stimulation test [GST]) at the time of hypoglycemia. RESULTS Only 23 of the 28 subjects with congenital hyperinsulinism had detectable insulin (median, 6.7 μIU/mL), and insulin was undetectable in all subjects with ketotic hypoglycemia. Compared with ketotic hypoglycemia, subjects with congenital hyperinsulinism had higher GST values (57 vs 13 mg/dL; ΔGST ≥30 mg/dL in 24 of 27 subjects with congenital hyperinsulinism vs 0 of 30 subjects with ketotic hypoglycemia) and C-peptide levels (1.55 vs 0.11 ng/mL), with lower levels of FFA (0.82 vs 2.51 mM) and IGFBP-1 (59.5 vs 634 ng/mL). At the time of hypoglycemia, the upper limits of β-hydroxybutyrate and FFA in subjects with congenital hyperinsulinism were higher than reported previously (β-hydroxybutyrate <1.8 mM and FFA <1.7 mM), providing the best sensitivity for congenital hyperinsulinism vs ketotic hypoglycemia. A C-peptide level ≥0.5 ng/mL was 89% sensitive and 100% specific, and an IGFBP-1 level ≤110 ng/mL was 85% sensitive and 96.6% specific. CONCLUSION Because low or undetectable insulin level during hypoglycemia does not exclude the diagnosis of hyperinsulinism, C-peptide and IGFBP-1 may inform the diagnosis of congenital hyperinsulinism. In this group of children with well-defined congenital hyperinsulinism, thresholds for "suppressed" β-hydroxybutyrate and FFA are higher than previously reported levels.
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24
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Hashimoto Y, Sakakibara A, Kawakita R, Hosokawa Y, Fujimaru R, Nakamura T, Fukushima H, Igarashi A, Masue M, Nishibori H, Tamagawa N, Murakami A, Hatake K, Yorifuji T. Focal form of congenital hyperinsulinism clearly detectable by contrast-enhanced computed tomography imaging. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2015; 2015:20. [PMID: 26379717 PMCID: PMC4570655 DOI: 10.1186/s13633-015-0016-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Accepted: 08/14/2015] [Indexed: 11/10/2022]
Abstract
The focal form of congenital hyperinsulinism (CHI) is characterized by a cluster of abnormal insulin-oversecreting β cells within a restricted area of the pancreas. Although identification of the focal lesion is very important in the management of CHI, it has been reported that imaging studies, including computed tomography (CT), magnetic resonance imaging (MRI) scans, or angiography, are not helpful in identifying the focal lesion. Currently, fluorine-18-L-dihydroxyphenylalanine positron emission tomography ((18)F-DOPA PET) is believed to be the only imaging modality that can identify the focal lesions. In this report, however, we present a case of a 7-month-old girl with the focal form of CHI, caused by a loss-of-function mutation in the ABCC8 gene, whose lesion was clearly visible as a hyperenhancing nodule on contrast-enhanced CT and dynamic MRI imaging.
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Affiliation(s)
- Yukiko Hashimoto
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima, Osaka 534-0021 Japan
| | - Azumi Sakakibara
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima, Osaka 534-0021 Japan
| | - Rie Kawakita
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima, Osaka 534-0021 Japan
| | - Yuki Hosokawa
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima, Osaka 534-0021 Japan
| | - Rika Fujimaru
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima, Osaka 534-0021 Japan
| | - Tetsuro Nakamura
- Department of Pediatric Surgery, Osaka City General Hospital, Osaka, Japan
| | - Hiroko Fukushima
- Department of Pathology, Osaka City General Hospital, Osaka, Japan
| | - Aiko Igarashi
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Michiya Masue
- Department of Pediatrics, Kizawa Memorial Hospital, Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Minokamo, Japan
| | - Hironori Nishibori
- Department of Pediatrics, Kizawa Memorial Hospital, Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Minokamo, Japan
| | | | - Akiko Murakami
- Clinical Research Center, Osaka City General Hospital, Osaka, Japan
| | - Kazue Hatake
- Clinical Research Center, Osaka City General Hospital, Osaka, Japan
| | - Tohru Yorifuji
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, 2-13-22 Miyakojima-hondori, Miyakojima, Osaka 534-0021 Japan ; Clinical Research Center, Osaka City General Hospital, Osaka, Japan
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25
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Zhang W, Liu L, Wen Z, Cheng J, Li C, Li X, Niu H, Wang F, Sheng H, Liu H. A compound heterozygous mutation of ABCC8 gene causing a diazoxide-unresponsive congenital hyperinsulinism with an atypical form: Not a focal lesion in the pancreas reported by ¹⁸F-DOPA-PET/CT scan. Gene 2015; 572:222-6. [PMID: 26162674 DOI: 10.1016/j.gene.2015.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 06/25/2015] [Accepted: 07/06/2015] [Indexed: 10/23/2022]
Abstract
Congenital hyperinsulinism (CHI) is a severe heterogeneous disorder due to dysregulation of insulin secretion from the pancreatic β-cells leading to severe hypoglycemia in infancy. 18-fluoro-l-3,4-dihydroxyphenylalanine positron emission tomography ((18)F‑DOPA‑PET)/CT is a useful tool in distinguishing between focal and diffuse disease preoperatively. But recent studies have suggested that the scanning may not be accurate as initially estimated. In this study we characterize a case of CHI with a compound heterozygous mutation of ABCC8 gene. The results of clinical investigation, gene mutation analysis, (18)F‑DOPA‑PET/CT scan, and pathological examination showed some new characteristics that have never been reported. The patient was unresponsive to medical therapy with diazoxide and received pancreatectomy twice. Genetic analysis identified a compound heterozygous mutation in ABCC8 genes. Imaging with (18)F‑DOPA‑PET/CT indicated a focal lesion in the head of the pancreas. The pathological diagnosis was an atypical form of CHI. The patient presented with a phenotype of atypical CHI unresponsive to diazoxide. It is considered that a relationship existed between the compound heterozygous mutation and the atypical form. (18)F‑DOPA‑PET/CT is a useful tool in distinguishing between focal and diffuse forms preoperatively but the accuracy is not 100%. The scan result is best combined with genetic analysis and intra-operative biopsy to confirm the histological subtypes. The combination will provide the optimal strategy for the surgical treatment of patients with CHI.
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Affiliation(s)
- Wen Zhang
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Li Liu
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou, China.
| | - Zhe Wen
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Jing Cheng
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Cuiling Li
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Xiuzhen Li
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huilin Niu
- Department of Pathology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Fenghua Wang
- Department of Pathology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huiying Sheng
- Department of Genetics and Endocrinology, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Hongsheng Liu
- Department of Radiology, Guangzhou Women and Children's Medical Center, Guangzhou, China
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26
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Jiao Y, Lumpkins K, Terhune J, Hruban RH, Klein A, Kinzler KW, Papadopoulos N, Vogelstein B, Strauch E. Intraductal papillary mucinous neoplasm in a neonate with congenital hyperinsulinism and a de novo germline SKIL gene mutation. Pancreatology 2015; 15:194-6. [PMID: 25464936 PMCID: PMC4387019 DOI: 10.1016/j.pan.2014.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 10/13/2014] [Accepted: 10/15/2014] [Indexed: 12/11/2022]
Abstract
A 3 day old infant with persistent severe hypoglycemia was found to have a cystic pancreatic tumor. Cessation of glucose infusion led to severe hypoglycemia. Pancreaticoduodenectomy was performed and revealed an intraductal papillary mucinous neoplasm (IPMN) with high-grade dysplasia. Sequencing of the IPMN revealed a KRAS gene mutation not present in surrounding normal tissues. Deep sequencing of the patient's blood for KRAS mutations showed no evidence of mosaicism. Whole exome sequencing of the blood of the patient and both parents revealed a de novo germline SKIL mutation in the child that was not present in either parent. This suggests a possible role for SKIL in the pathogenesis of pancreatic tumors.
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Affiliation(s)
- Yuchen Jiao
- Departments of Oncology and Pathology The Sol Goldman Pancreatic Cancer Research Center The Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Kimberly Lumpkins
- Division of Pediatric Surgery Department of Surgery University of Maryland School of Medicine Baltimore, Maryland,Corresponding author 22 S. Greene St N4E35 Baltimore MD 21201 410-328-5730 ph/ 410-328-0652 fax
| | - Julia Terhune
- Division of Pediatric Surgery Department of Surgery University of Maryland School of Medicine Baltimore, Maryland
| | - Ralph H. Hruban
- Departments of Oncology and Pathology The Sol Goldman Pancreatic Cancer Research Center The Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Alison Klein
- Departments of Oncology and Pathology The Sol Goldman Pancreatic Cancer Research Center The Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Kenneth W. Kinzler
- Departments of Oncology and Pathology The Sol Goldman Pancreatic Cancer Research Center The Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Nickolas Papadopoulos
- Departments of Oncology and Pathology The Sol Goldman Pancreatic Cancer Research Center The Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Bert Vogelstein
- Departments of Oncology and Pathology The Sol Goldman Pancreatic Cancer Research Center The Sidney Kimmel Comprehensive Cancer Center Johns Hopkins University School of Medicine Baltimore, Maryland
| | - Eric Strauch
- Division of Pediatric Surgery Department of Surgery University of Maryland School of Medicine Baltimore, Maryland
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Shi Y, Avatapalle HB, Skae MS, Padidela R, Newbould M, Rigby L, Flanagan SE, Ellard S, Rahier J, Clayton PE, Dunne MJ, Banerjee I, Cosgrove KE. Increased plasma incretin concentrations identifies a subset of patients with persistent congenital hyperinsulinism without KATP channel gene defects. J Pediatr 2015; 166:191-4. [PMID: 25444530 DOI: 10.1016/j.jpeds.2014.09.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 07/30/2014] [Accepted: 09/09/2014] [Indexed: 11/26/2022]
Abstract
Congenital hyperinsulinism causes profound hypoglycemia, which may persist or resolve spontaneously. Among 13 children with congenital hyperinsulinism, elevated incretin hormone concentrations were detected in 2 with atypical, persistent disease. We suggest that incretin biomarkers may identify these patients, and that elevated hormone levels may contribute to their pathophysiology.
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Affiliation(s)
- Yanqin Shi
- Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom
| | - Hima B Avatapalle
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Mars S Skae
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Raja Padidela
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Melanie Newbould
- Department of Pediatric Histopathology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Lindsey Rigby
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, United Kingdom
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, United Kingdom
| | - Jacques Rahier
- Department of Pathology, Cliniques Universitaires Saint Luc, Brussels, Belgium
| | - Peter E Clayton
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom; Manchester Academic Health Science Centre, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Mark J Dunne
- Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Pediatric Endocrinology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | - Karen E Cosgrove
- Faculty of Life Sciences, University of Manchester, Manchester, United Kingdom.
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28
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Mohnike K, Wieland I, Barthlen W, Vogelgesang S, Empting S, Mohnike W, Meissner T, Zenker M. Clinical and genetic evaluation of patients with KATP channel mutations from the German registry for congenital hyperinsulinism. Horm Res Paediatr 2014; 81:156-68. [PMID: 24401662 DOI: 10.1159/000356905] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 10/03/2013] [Indexed: 11/19/2022] Open
Abstract
Congenital hyperinsulinism (CHI) causes hypoglycemia due to irregular insulin secretion. In infants, a rapid diagnosis and appropriate management to avoid severe hypoglycemia is mandatory. CHI is a heterogeneous condition at the clinical and genetic level, and disease-causing genes have been identified in about half of the patients. The majority of mutations have been identified in the ABCC8 and KCNJ11 genes encoding subunits of the KATP channel responsible for two distinct histological forms. The diffuse form is caused by autosomal recessive or dominant inherited mutations, whereas the focal form is caused by a paternally transmitted recessive mutation and a second somatic event. We report on an unselected cohort of 136 unrelated patients from the German CHI registry. Mutations in either the ABCC8 or KCNJ11 gene were identified in 61 of these patients (45%). In total, 64 different mutations including 38 novel ones were detected in this cohort. We observed biparental (recessive) inheritance in 34% of mutation-positive patients, dominant inheritance in 11% and paternal transmission of a mutation associated with a focal CHI type in 38%. In addition, we observed inheritance patterns that do not exactly follow the classical recessive or dominant mode, further adding to the genetic complexity of this disease.
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Affiliation(s)
- Klaus Mohnike
- Department of Pediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
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29
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Montravers F, Arnoux JB, Ribeiro MJ, Kerrou K, Nataf V, Galmiche L, Aigrain Y, Bellanné-Chantelot C, Saint-Martin C, Ohnona J, Balogova S, Huchet V, Michaud L, Talbot JN, de Lonlay P. Strengths and limitations of using 18fluorine-fluorodihydroxyphenylalanine PET/CT for congenital hyperinsulinism. Expert Rev Endocrinol Metab 2014; 9:477-485. [PMID: 30736210 DOI: 10.1586/17446651.2014.949240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
18fluorine-fluorodihydroxyphenylalanine (FDOPA) PET/CT is currently the first-line imaging technique to distinguish between focal and diffuse forms of congenital hyperinsulinism (CHI) and to accurately localize focal forms. However, this technique has a number of limitations, mainly the very small size of focal forms or inversely a very large focal form mimicking a diffuse form, and misinterpretation of physiologic uptake masking hot spots or inversely mimicking focal forms. The other limitation is the limited availability of the radiopharmaceutical. FDOPA PET/CT has no recognized competitor to date among the available morphologic and functional imaging techniques. Other potential approaches using specific tracers for positron emission tomography (PET) are discussed, using radiopharmaceuticals specific for β cell mass or targeting somatostatin receptors. These radiopharmaceuticals can be labeled with gallium-68, a PET emitter readily available in PET centers equipped with 68Ge/68Ga generators.
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Affiliation(s)
- Françoise Montravers
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jean-Baptiste Arnoux
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Maria-Joao Ribeiro
- c Service de médecine nucléaire, CHRU, Université François Rabelais, INSERM U930, Tours, France
| | - Khaldoun Kerrou
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Valérie Nataf
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Louise Galmiche
- d Service d'anatomo-pathologie, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Yves Aigrain
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
| | - Christine Bellanné-Chantelot
- e Département de génétique, AP-HP Groupe Hospitalier Pitié-Salpétrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Cécile Saint-Martin
- e Département de génétique, AP-HP Groupe Hospitalier Pitié-Salpétrière, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jessica Ohnona
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Sona Balogova
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
- f Department of nuclear medicine, Comenius University and St. Elisabeth Institute, Bratislava, Slovakia
| | - Virginie Huchet
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Laure Michaud
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Jean-Noël Talbot
- a Service de médecine nucléaire, Hôpital Tenon, AP-HP and Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Pascale de Lonlay
- b Centre de référence des maladies héréditaires du métabolisme de l'enfant, et l'adulte, AP-HP Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France
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30
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Jodal A, Lankat-Buttgereit B, Brom M, Schibli R, Béhé M. A comparison of three (67/68)Ga-labelled exendin-4 derivatives for β-cell imaging on the GLP-1 receptor: the influence of the conjugation site of NODAGA as chelator. EJNMMI Res 2014; 4:31. [PMID: 25006548 PMCID: PMC4078388 DOI: 10.1186/s13550-014-0031-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/03/2014] [Indexed: 11/26/2022] Open
Abstract
Background Various diseases derive from pathologically altered β-cells. Their function can be increased, leading to hyperinsulinism, or decreased, resulting in diabetes. Non-invasive imaging of the β-cell-specific glucagon-like peptide receptor-1 (GLP-1R) would allow the assessment of both β-cell mass and derived tumours, potentially improving the diagnosis of various conditions. We tested three new 67/68Ga-labelled derivatives of exendin-4, an agonist of GLP-1R, in vitro and in vivo. We determined the influence of the chelator NODAGA conjugated to resident lysines either at positions 12 and 27 or the C-terminally attached lysine at position 40 on the binding and kinetics of the peptide. Methods Binding and internalisation of 67Ga-labelled Ex4NOD12, Ex4NOD27 and Ex4NOD40 were tested on Chinese hamster lung (CHL) cells stably transfected to express the GLP-1 receptor (GLP-1R). In vivo biodistribution of 68Ga-labelled peptides was investigated in CD1 nu/nu mice with subcutaneous CHL-GLP-1R positive tumours; the specificity of the binding to GLP-1R was determined by pre-injecting excess peptide. Results All peptides showed good in vitro binding affinities to GLP-1R in the range of 29 to 54 nM. 67/68Ga-Ex4NOD40 and 67/68Ga-Ex4NOD12 show excellent internalisation (>30%) and high specific uptake in GLP-1R positive tissue, but high activity was also found in the kidneys. Conclusions We show that of the three peptides, Ga-Ex4NOD40 and Ga-Ex4NOD12 demonstrate the most favourable in vitro properties and in vivo binding to GLP-1R positive tissue. Therefore, we conclude that the lysines at positions 12 and 40 might preferentially be utilised for modifying exendin-4.
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Affiliation(s)
- Andreas Jodal
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, OIPA/103, Villigen 5232, Switzerland
| | - Brigitte Lankat-Buttgereit
- Faculty of Medicine, Department of Gastroenterology, Endocrinology and Metabolism, University of Marburg, Marburg 35037, Germany
| | - Maarten Brom
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen 6525, The Netherlands
| | - Roger Schibli
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, OIPA/103, Villigen 5232, Switzerland ; Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich 8092, Switzerland
| | - Martin Béhé
- Center for Radiopharmaceutical Sciences ETH-PSI-USZ, Paul Scherrer Institute, OIPA/103, Villigen 5232, Switzerland
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31
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Abstract
Hypoglycemia in the pediatric population is a common finding important to recognize and manage to prevent brain injury. Recent advances in molecular genetics have provided new insight into its biochemical and physiologic basis and have led to more appropriate and specific treatment. Although a major cause of brain injury in pediatrics, the ability to predict the long-term outcome in these patients remains difficult. Identification of these at-risk individuals is important. The physiologic adaptations associated with transition from fetal to neonatal life are now better understood thus allowing for improved surveillance and management. Despite these advances, analytical limitations of point-of-care testing instruments at low glucose concentration continue to persist, This review aims to address these questions and provide an overview of pediatric hypoglycemia and the molecular pathways involved.
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Abstract
Persistent hyperinsulinaemic hypoglycaemia in infancy (PHHI) is a heterogeneous condition characterised by unregulated insulin secretion in response to a low blood glucose level. It is the most common cause of severe and persistent hypoglycaemia in neonates. It is extremely important to recognise this condition early and institute appropriate management to prevent significant brain injury leading to complications like epilepsy, cerebral palsy and neurological impairment. Histologically, PHHI is divided mainly into three types-diffuse, focal and atypical disease. Fluorine-18-l-3,4-dihydroxyphenylalanine positron emission tomography (18F-DOPA-PET/CT) scan allows differentiation between diffuse and focal diseases. The diffuse form is inherited in an autosomal recessive (or dominant) manner whereas the focal form is sporadic in inheritance and is localised to a small region of the pancreas. The molecular basis of PHHI involves defects in key genes (ABCC8, KCNJ11, GCK, SLC16A1, HADH, UCP2, HNF4A and GLUD1) that regulate insulin secretion. Focal lesions are cured by lesionectomy whereas diffuse disease (unresponsive to medical therapy) will require a near-total pancreatectomy with a risk of developing diabetes mellitus and pancreatic exocrine insufficiency. Open surgery is the traditional approach to pancreatic resection. However, recent advances in laparoscopic surgery have led to laparoscopic near-total pancreatectomy for diffuse lesions and laparoscopic distal pancreatectomy for focal lesions distal to the head of the pancreas.
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Affiliation(s)
- Pratik Shah
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London
| | - Huseyin Demirbilek
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London
| | - Khalid Hussain
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London.
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Stevens A, De Leonibus C, Hanson D, Dowsey AW, Whatmore A, Meyer S, Donn RP, Chatelain P, Banerjee I, Cosgrove KE, Clayton PE, Dunne MJ. Network analysis: a new approach to study endocrine disorders. J Mol Endocrinol 2014; 52:R79-93. [PMID: 24085748 DOI: 10.1530/jme-13-0112] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Systems biology is the study of the interactions that occur between the components of individual cells - including genes, proteins, transcription factors, small molecules, and metabolites, and their relationships to complex physiological and pathological processes. The application of systems biology to medicine promises rapid advances in both our understanding of disease and the development of novel treatment options. Network biology has emerged as the primary tool for studying systems biology as it utilises the mathematical analysis of the relationships between connected objects in a biological system and allows the integration of varied 'omic' datasets (including genomics, metabolomics, proteomics, etc.). Analysis of network biology generates interactome models to infer and assess function; to understand mechanisms, and to prioritise candidates for further investigation. This review provides an overview of network methods used to support this research and an insight into current applications of network analysis applied to endocrinology. A wide spectrum of endocrine disorders are included ranging from congenital hyperinsulinism in infancy, through childhood developmental and growth disorders, to the development of metabolic diseases in early and late adulthood, such as obesity and obesity-related pathologies. In addition to providing a deeper understanding of diseases processes, network biology is also central to the development of personalised treatment strategies which will integrate pharmacogenomics with systems biology of the individual.
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Affiliation(s)
- A Stevens
- Faculty of Medical and Human Sciences, Institute of Human Development, University of Manchester, Manchester, UK Manchester Academic Health Science Centre, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust, 5th Floor, Oxford Road, Manchester M13 9WL, UK Paediatric and Adolescent Oncology, The University of Manchester, Manchester M13 9WL, UK Stem Cell and Leukaemia Proteomics Laboratory, School of Cancer and Imaging Sciences, The University of Manchester, Manchester M20 4BX, UK Musculoskeletal Research Group, NIHR BRU, University of Manchester, Manchester M13 9PT, UK Department Pediatrie, Hôpital Mère-Enfant, Université Claude Bernard, 69677 Lyon, France Faculty of Life Sciences, University of Manchester, Manchester M13 9NT, UK
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34
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Skae M, Avatapalle HB, Banerjee I, Rigby L, Vail A, Foster P, Charalambous C, Bowden L, Padidela R, Patel L, Ehtisham S, Cosgrove KE, Dunne MJ, Clayton PE. Reduced Glycemic Variability in Diazoxide-Responsive Children with Congenital Hyperinsulinism Using Supplemental Omega-3-Polyunsaturated Fatty Acids; A Pilot Trial with MaxEPA(R.). Front Endocrinol (Lausanne) 2014; 5:31. [PMID: 24659984 PMCID: PMC3952031 DOI: 10.3389/fendo.2014.00031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 02/21/2014] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE Congenital hyperinsulinism (CHI) is a rare condition of hypoglycemia where therapeutic options are limited and often complicated by side-effects. Omega-3-polyunsaturated fatty acids (PUFA), which can suppress cardiac myocyte electrical activity, may also reduce ion channel activity in insulin-secreting cells. PUFA supplements in combination with standard medical treatment may improve glucose profile and may reduce glycemic variability in diazoxide-responsive CHI. DESIGN Open label pilot trial with MaxEPA(R) liquid (eicosapentaenoic and docosahexaenoic acid) PUFA (3 ml/day for 21 days) in diazoxide-responsive CHI patients (https://eudract.ema.europa.eu/, EudraCT number 201100363333). METHODS Glucose levels were monitored pre-treatment, end of treatment, and at follow-up by subcutaneous continuous glucose monitoring systems (CGMS) in 13 patients (7 girls) who received PUFA. Outcome measures were an improved glucose profile, reduced glycemic variability quantified by a reduction in the frequency of glucose levels <4 and >10 mmol/l, and safety of PUFA. All children were analyzed either as intention to treat (n = 13) or as per protocol (n = 7). RESULTS Mean (%) CGMS glucose levels increased by 0.1 mmol/l (2%) in intention to treat and by 0.4 mmol/l (8%) in per protocol analysis (n = 7). The frequency of CGMS <4 mmol/l was significantly less at the end of treatment than in the pre-treatment period [556 (7%) vs. 749 (10%)]. Similarly, the frequency of CGMS >10 mmol/l, was also less at the end of treatment [27 (0.3%) vs. 49 (0.7%)]. Except for one child with increased LDL cholesterol, all safety parameters were normal. CONCLUSION MaxEPA(R) was safe and reduced glycemic variability, but did not increase glucose profiles significantly in diazoxide-responsive CHI. The supplemental value of PUFA should be evaluated in a comprehensive clinical trial.
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Affiliation(s)
- Mars Skae
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Hima Bindu Avatapalle
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
- *Correspondence: Indraneel Banerjee, Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Oxford Road, Manchester M13 9WL, UK e-mail: ;
| | - Lindsey Rigby
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Andy Vail
- Institute of Population Health, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Peter Foster
- School of Mathematics, University of Manchester, Manchester, UK
| | | | - Louise Bowden
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Leena Patel
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Sarah Ehtisham
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | | | - Mark J. Dunne
- Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Peter E. Clayton
- Department of Paediatric Endocrinology, Manchester Academic Health Science Centre, Royal Manchester Children’s Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Institute of Human Development, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
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