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Rapini N, Delvecchio M, Mucciolo M, Ruta R, Rabbone I, Cherubini V, Zucchini S, Cianfarani S, Prandi E, Schiaffini R, Bizzarri C, Piccini B, Maltoni G, Predieri B, Minuto N, Di Paola R, Giordano M, Tinto N, Grasso V, Russo L, Tiberi V, Scaramuzza A, Frontino G, Maggio MC, Musolino G, Piccinno E, Tinti D, Carrera P, Mozzillo E, Cappa M, Iafusco D, Bonfanti R, Novelli A, Barbetti F. The Changing Landscape of Neonatal Diabetes Mellitus in Italy Between 2003 and 2022. J Clin Endocrinol Metab 2024; 109:2349-2357. [PMID: 38408297 PMCID: PMC11319002 DOI: 10.1210/clinem/dgae095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/29/2024] [Accepted: 02/15/2024] [Indexed: 02/28/2024]
Abstract
CONTEXT In the last decade the Sanger method of DNA sequencing has been replaced by next-generation sequencing (NGS). NGS is valuable in conditions characterized by high genetic heterogeneity such as neonatal diabetes mellitus (NDM). OBJECTIVE To compare results of genetic analysis of patients with NDM and congenital severe insulin resistance (c.SIR) identified in Italy in 2003-2012 (Sanger) vs 2013-2022 (NGS). METHODS We reviewed clinical and genetic records of 104 cases with diabetes onset before 6 months of age (NDM + c.SIR) of the Italian dataset. RESULTS Fifty-five patients (50 NDM + 5 c.SIR) were identified during 2003-2012 and 49 (46 NDM + 3 c.SIR) in 2013-2022. Twenty-year incidence was 1:103 340 (NDM) and 1:1 240 082 (c.SIR) live births. Frequent NDM/c.SIR genetic defects (KCNJ11, INS, ABCC8, 6q24, INSR) were detected in 41 and 34 probands during 2003-2012 and 2013-2022, respectively. We identified a pathogenic variant in rare genes in a single proband (GATA4) (1/42 or 2.4%) during 2003-2012 and in 8 infants (RFX6, PDX1, GATA6, HNF1B, FOXP3, IL2RA, LRBA, BSCL2) during 2013-2022 (8/42 or 19%, P = .034 vs 2003-2012). Notably, among rare genes 5 were recessive. Swift and accurate genetic diagnosis led to appropriate treatment: patients with autoimmune NDM (FOXP3, IL2RA, LRBA) were subjected to bone marrow transplant; patients with pancreas agenesis/hypoplasia (RFX6, PDX1) were supplemented with pancreatic enzymes, and the individual with lipodystrophy caused by BSCL2 was started on metreleptin. CONCLUSION NGS substantially improved diagnosis and precision therapy of monogenic forms of neonatal diabetes and c.SIR in Italy.
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Affiliation(s)
- Novella Rapini
- Monogenic Diabetes Clinic, Endocrinology and Diabetes Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Maurizio Delvecchio
- Metabolic Disorder and Diabetes Unit, “Giovanni XXIII” Children Hospital, 70100 Bari, Italy
- Unit of Pediatrics, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, 67100 L'Aquila, Italy
| | - Mafalda Mucciolo
- Translational Cytogenomics Research Unit, Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, 00146 Rome, Italy
| | - Rosario Ruta
- Translational Cytogenomics Research Unit, Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, 00146 Rome, Italy
| | - Ivana Rabbone
- Department of Health Sciences, Division of Pediatrics, University of Eastern Piedmont, 28100 Novara, Italy
| | - Valentino Cherubini
- Pediatric Endocrinology and Diabetology Unit, Department of Women's and Children's Health, Azienda Ospedaliero Universitaria delle Marche, G. Salesi Hospital, 60126 Ancona, Italy
| | - Stefano Zucchini
- Pediatric Endocrine Unit, University Hospital of Bologna Sant’Orsola-Malpighi, 40138 Bologna, Italy
| | - Stefano Cianfarani
- Endocrinology and Diabetes Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
- Department of Systems Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
- Department of Women's and Children's Health, Karolinska Institutet, 17177 Stockholm, Sweden
| | - Elena Prandi
- Pediatrics Clinic, University of Brescia and ASST Spedali Civili of Brescia, 25123 Brescia, Italy
| | - Riccardo Schiaffini
- Endocrinology and Diabetes Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Carla Bizzarri
- Endocrinology and Diabetes Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Barbara Piccini
- Endocrinology and Diabetology Unit, Meyer University Children's Hospital IRCCS, 50139 Florence, Italy
| | - Giulio Maltoni
- Pediatric Endocrine Unit, University Hospital of Bologna Sant’Orsola-Malpighi, 40138 Bologna, Italy
| | - Barbara Predieri
- Department of Medical and Surgical Sciences of Mother, Children and Adults, Pediatric Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Nicola Minuto
- Regional Center for Pediatric Diabetes, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Rossella Di Paola
- Research Unit of Diabetes and Endocrine Diseases, Fondazione IRCCS Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy
| | - Mara Giordano
- Department of Health Sciences, University of Eastern Piedmont, 28100 Novara, Italy
- Laboratory of Genetics, “Maggiore della Carità” Hospital, 28100 Novara, Italy
| | - Nadia Tinto
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II/CEINGE Advanced Biotechnologies Franco Salvatore, 80131 Naples, Italy
| | - Valeria Grasso
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Lucia Russo
- Department of Experimental Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Valentina Tiberi
- Pediatric Endocrinology and Diabetology Unit, Department of Women's and Children's Health, Azienda Ospedaliero Universitaria delle Marche, G. Salesi Hospital, 60126 Ancona, Italy
| | - Andrea Scaramuzza
- Diabetes and Endocrine Service, Pediatric Unit, ASST Cremona, Maggiore Hospital, 26100 Cremona, Italy
| | - Giulio Frontino
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | | | - Gianluca Musolino
- Growth Disorders, Endocrinology and Diabetology Clinic, Filippo del Ponte Pediatric Hospital, ASST Sette Laghi, 21100 Varese, Italy
| | - Elvira Piccinno
- Metabolic Disorder and Diabetes Unit, “Giovanni XXIII” Children Hospital, 70100 Bari, Italy
| | - Davide Tinti
- Department of Pediatrics, University of Turin, 10126 Turin, Italy
| | - Paola Carrera
- Genomics for the Diagnosis of Human Pathologies, San Raffaele Scientific Institute, Center for Omics sciences @OSR, 20132 Milan, Italy
- Laboratory of Molecular Genetics and Cytogenetics, San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Enza Mozzillo
- Department of Translational Medical Science, Section of Pediatrics, Università degli Studi di Napoli Federico II, 80131 Naples, Italy
| | - Marco Cappa
- Research Area for Innovative Therapies in Endocrinopathies, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
| | - Dario Iafusco
- Department of Pediatrics, University of Campania Luigi Vanvitelli, 81100 Naples, Italy
| | - Riccardo Bonfanti
- Department of Pediatrics, Pediatric Diabetology Unit, Diabetes Research Institute, IRCCS Ospedale San Raffaele and Vita Salute San Raffaele University, 20132 Milan, Italy
| | - Antonio Novelli
- Translational Cytogenomics Research Unit, Laboratory of Medical Genetics, Bambino Gesù Children's Hospital, IRCCS, 00146 Rome, Italy
| | - Fabrizio Barbetti
- Monogenic Diabetes Clinic, Endocrinology and Diabetes Unit, Bambino Gesù Children's Hospital, IRCCS, 00165 Rome, Italy
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Foglino R, Barbetti F, Morotti E, Castorani V, Rigamonti A, Frontino G, Barera G, Bonfanti R. Case report: A case of Rabson-Mendenhall syndrome: long-term follow-up and therapeutic management with empagliflozin. Front Genet 2024; 15:1414451. [PMID: 38978877 PMCID: PMC11228259 DOI: 10.3389/fgene.2024.1414451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/31/2024] [Indexed: 07/10/2024] Open
Abstract
Background: Rabson-Mendenhall syndrome (RMS), a rare disorder characterized by severe insulin resistance due to biallelic loss-of-function variants of the insulin receptor gene (INSR), presents therapeutic challenges (OMIM: 262190). This case study explores the efficacy of adjunctive therapy with sodium-glucose cotransporter 2 inhibitors (SGLT2is) in the management of RMS in an 11-year-old male patient with compound heterozygous pathogenic variants of INSR. Methods: Despite initial efforts to regulate glycemia with insulin therapy followed by metformin treatment, achieving stable glycemic control presented a critical challenge, characterized by persistent hyperinsulinism and variable fluctuations in glucose levels. Upon the addition of empagliflozin to metformin, notable improvements in glycated hemoglobin (HbA1c) and time in range (TIR) were observed over a 10-month period. Results: After 10 months of treatment, empagliflozin therapy led to a clinically meaningful reduction in HbA1c levels, decreasing from 8.5% to 7.1%, along with an improvement in TIR from 47% to 74%. Furthermore, regular monitoring effectively averted normoglycemic ketoacidosis, a rare complication associated with SGLT2 inhibitor therapy. Conclusion: This case highlights the potential of SGLT2i as adjunctive therapy in RMS management, particularly in stabilizing glycemic variability. However, further research is warranted to elucidate the long-term efficacy and safety of this therapeutic approach in RMS and similar insulin resistance syndromes.
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Affiliation(s)
- R Foglino
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - F Barbetti
- Monogenic Diabetes Clinic, Unit of Endocrinology and Diabetes, Bambino Gesù Children Hospital IRCCS, Rome, Italy
| | - E Morotti
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - V Castorani
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - A Rigamonti
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - G Frontino
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - G Barera
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
| | - R Bonfanti
- Pediatric Diabetes Unit IRCCS Ospedale San Raffaele, Vita Salute San Raffaele University, Milan, Italy
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Koca SB, Kulali MA, Göğüş B, Demirbilek H. Type A insulin resistance syndrome due to a novel heterozygous c.3486_3503del (p.Arg1163_Ala1168del) INSR gene mutation in an adolescent girl and her mother. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2024; 68:e210305. [PMID: 38289143 PMCID: PMC10948035 DOI: 10.20945/2359-4292-2021-0305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 12/05/2022] [Indexed: 02/01/2024]
Abstract
Mutations in the insulin receptor (INSR) gene may present with variable clinical phenotypes. We report herein a novel heterozygous INSR mutation in an adolescent girl with type A insulin resistance syndrome and her mother.The index case was a 12-year-old girl without obesity who presented with excessive hair growth, especially in the chest and back area, and hyperpigmentation on the back of the neck (acanthosis nigricans). Acanthosis nigricans was first observed at the age of 11 years. On physical examination, the patient had acanthosis nigricans and hypertrichosis with no acne. Systolic and diastolic blood pressure measurement was within the normal range for age and sex. Laboratory tests revealed fasting hyperglycemia, fasting and postprandial hyperinsulinemia, elevated HbA1c level, and biochemical hyperandrogenemia. Fasting plasma lipids were normal. A diagnosis of type A insulin resistance syndrome was considered, and INSR gene mutation analysis was performed. Next generation sequence analysis was performed with the use of primers containing exon/exon-intron junctions in the INSR gene, and a novel heterozygous c.3486_3503delGAGAAACTGCATGGTCGC/p.Arg1163_Ala1168del change was detected in exon 19 of the INSR gene. In segregation analysis, the same variant was detected in the patient's mother, who had a milder clinical phenotype.We reported a novel, heterozygous, p.Arg1163_Ala1168del mutation in exon 19 of the INSR gene in a patient with type A insulin resistance syndrome, expanding the mutation database. The same mutation was associated with variable phenotypical severity in two subjects within the same family.
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Affiliation(s)
- Serkan Bilge Koca
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, Afyonkarahisar, Turkey,
| | - Melike Ataseven Kulali
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Genetics, Afyonkarahisar, Turkey
| | - Başak Göğüş
- Afyonkarahisar Health Sciences University, Faculty of Medicine, Department of Medical Genetics, Afyonkarahisar, Turkey
| | - Hüseyin Demirbilek
- Hacettepe University, Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, Ankara, Turkey
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Nisa KU, Tarfeen N, Mir SA, Waza AA, Ahmad MB, Ganai BA. Molecular Mechanisms in the Etiology of Polycystic Ovary Syndrome (PCOS): A Multifaceted Hypothesis Towards the Disease with Potential Therapeutics. Indian J Clin Biochem 2024; 39:18-36. [PMID: 38223007 PMCID: PMC10784448 DOI: 10.1007/s12291-023-01130-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/01/2023] [Indexed: 03/28/2023]
Abstract
Among the premenopausal women, Polycystic Ovary Syndrome (PCOS) is the most prevalent endocrinopathy affecting the reproductive system and metabolic rhythms leading to disrupted menstrual cycle. Being heterogeneous in nature it is characterized by complex symptomology of oligomennorhoea, excess of androgens triggering masculine phenotypic appearance and/or multiple follicular ovaries. The etiology of this complex disorder remains somewhat doubtful and the researchers hypothesize multisystem links in the pathogenesis of this disease. In this review, we attempt to present several hypotheses that tend to contribute to the etiology of PCOS. Metabolic inflexibility, aberrant pattern of gonadotropin signaling along with the evolutionary, genetic and environmental factors have been discussed. Considered a lifelong endocrinological implication, no universal treatment is available for PCOS so far however; multiple drug therapy is often advised along with simple life style intervention is mainly advised to manage its cardinal symptoms. Here we aimed to present a summarized view of pathophysiological links of PCOS with potential therapeutic strategies.
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Affiliation(s)
- Khair Ul Nisa
- Department of Environmental Science, University of Kashmir, Srinagar, 190006 India
- Centre of Research for Development (CORD), University of Kashmir, Srinagar, 190006 India
| | - Najeebul Tarfeen
- Centre of Research for Development (CORD), University of Kashmir, Srinagar, 190006 India
| | - Shahnaz Ahmad Mir
- Department of Endocrinology, Government Medical College, Shireen Bagh, Srinagar, 190010 India
| | - Ajaz Ahmad Waza
- Multidisciplinary Research Unit (MRU), Government Medical Collage (GMC), Srinagar, 190010 India
| | - Mir Bilal Ahmad
- Department of Biochemistry, University of Kashmir, Srinagar, 190006 India
| | - Bashir Ahmad Ganai
- Centre of Research for Development (CORD), University of Kashmir, Srinagar, 190006 India
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5
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Le TKC, Dao XD, Nguyen DV, Luu DH, Bui TMH, Le TH, Nguyen HT, Le TN, Hosaka T, Nguyen TTT. Insulin signaling and its application. Front Endocrinol (Lausanne) 2023; 14:1226655. [PMID: 37664840 PMCID: PMC10469844 DOI: 10.3389/fendo.2023.1226655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/19/2023] [Indexed: 09/05/2023] Open
Abstract
The discovery of insulin in 1921 introduced a new branch of research into insulin activity and insulin resistance. Many discoveries in this field have been applied to diagnosing and treating diseases related to insulin resistance. In this mini-review, the authors attempt to synthesize the updated discoveries to unravel the related mechanisms and inform the development of novel applications. Firstly, we depict the insulin signaling pathway to explain the physiology of insulin action starting at the receptor sites of insulin and downstream the signaling of the insulin signaling pathway. Based on this, the next part will analyze the mechanisms of insulin resistance with two major provenances: the defects caused by receptors and the defects due to extra-receptor causes, but in this study, we focus on post-receptor causes. Finally, we discuss the recent applications including the diseases related to insulin resistance (obesity, cardiovascular disease, Alzheimer's disease, and cancer) and the potential treatment of those based on insulin resistance mechanisms.
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Affiliation(s)
- Thi Kim Chung Le
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Xuan Dat Dao
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Dang Vung Nguyen
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Duc Huy Luu
- Department of Biopharmaceuticals, Institute of Chemistry, Vietnam Academy of Science and Technology, Hanoi, Vietnam
| | - Thi Minh Hanh Bui
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Thi Huong Le
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Huu Thang Nguyen
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Tran Ngoan Le
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Toshio Hosaka
- Department of Food and Nutritional Sciences, University of Shizuoka, Shizuoka, Japan
| | - Thi Thu Thao Nguyen
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
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Cook TW, Wilstermann AM, Mitchell JT, Arnold NE, Rajasekaran S, Bupp CP, Prokop JW. Understanding Insulin in the Age of Precision Medicine and Big Data: Under-Explored Nature of Genomics. Biomolecules 2023; 13:257. [PMID: 36830626 PMCID: PMC9953665 DOI: 10.3390/biom13020257] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/20/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023] Open
Abstract
Insulin is amongst the human genome's most well-studied genes/proteins due to its connection to metabolic health. Within this article, we review literature and data to build a knowledge base of Insulin (INS) genetics that influence transcription, transcript processing, translation, hormone maturation, secretion, receptor binding, and metabolism while highlighting the future needs of insulin research. The INS gene region has 2076 unique variants from population genetics. Several variants are found near the transcriptional start site, enhancers, and following the INS transcripts that might influence the readthrough fusion transcript INS-IGF2. This INS-IGF2 transcript splice site was confirmed within hundreds of pancreatic RNAseq samples, lacks drift based on human genome sequencing, and has possible elevated expression due to viral regulation within the liver. Moreover, a rare, poorly characterized African population-enriched variant of INS-IGF2 results in a loss of the stop codon. INS transcript UTR variants rs689 and rs3842753, associated with type 1 diabetes, are found in many pancreatic RNAseq datasets with an elevation of the 3'UTR alternatively spliced INS transcript. Finally, by combining literature, evolutionary profiling, and structural biology, we map rare missense variants that influence preproinsulin translation, proinsulin processing, dimer/hexamer secretory storage, receptor activation, and C-peptide detection for quasi-insulin blood measurements.
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Affiliation(s)
- Taylor W. Cook
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
| | | | - Jackson T. Mitchell
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
| | - Nicholas E. Arnold
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
| | - Surender Rajasekaran
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
- Office of Research, Corewell Health, Grand Rapids, MI 49503, USA
| | - Caleb P. Bupp
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
- Division of Medical Genetics, Corewell Health, Grand Rapids, MI 49503, USA
| | - Jeremy W. Prokop
- Department of Pediatrics and Human Development, College of Human Medicine, Michigan State University, Grand Rapids, MI 49503, USA
- Department of Pharmacology and Toxicology, Michigan State University, East Lansing, MI 48824, USA
- Office of Research, Corewell Health, Grand Rapids, MI 49503, USA
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Dapas M, Dunaif A. Deconstructing a Syndrome: Genomic Insights Into PCOS Causal Mechanisms and Classification. Endocr Rev 2022; 43:927-965. [PMID: 35026001 PMCID: PMC9695127 DOI: 10.1210/endrev/bnac001] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Indexed: 01/16/2023]
Abstract
Polycystic ovary syndrome (PCOS) is among the most common disorders in women of reproductive age, affecting up to 15% worldwide, depending on the diagnostic criteria. PCOS is characterized by a constellation of interrelated reproductive abnormalities, including disordered gonadotropin secretion, increased androgen production, chronic anovulation, and polycystic ovarian morphology. It is frequently associated with insulin resistance and obesity. These reproductive and metabolic derangements cause major morbidities across the lifespan, including anovulatory infertility and type 2 diabetes (T2D). Despite decades of investigative effort, the etiology of PCOS remains unknown. Familial clustering of PCOS cases has indicated a genetic contribution to PCOS. There are rare Mendelian forms of PCOS associated with extreme phenotypes, but PCOS typically follows a non-Mendelian pattern of inheritance consistent with a complex genetic architecture, analogous to T2D and obesity, that reflects the interaction of susceptibility genes and environmental factors. Genomic studies of PCOS have provided important insights into disease pathways and have indicated that current diagnostic criteria do not capture underlying differences in biology associated with different forms of PCOS. We provide a state-of-the-science review of genetic analyses of PCOS, including an overview of genomic methodologies aimed at a general audience of non-geneticists and clinicians. Applications in PCOS will be discussed, including strengths and limitations of each study. The contributions of environmental factors, including developmental origins, will be reviewed. Insights into the pathogenesis and genetic architecture of PCOS will be summarized. Future directions for PCOS genetic studies will be outlined.
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Affiliation(s)
- Matthew Dapas
- Department of Human Genetics, University of Chicago, Chicago, IL, USA
| | - Andrea Dunaif
- Division of Endocrinology, Diabetes and Bone Disease, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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8
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De Meyts P. [The insulin receptor discovery is 50 years old - A review of achieved progress]. Biol Aujourdhui 2022; 216:7-28. [PMID: 35876517 DOI: 10.1051/jbio/2022007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Indexed: 06/15/2023]
Abstract
The isolation of insulin from the pancreas and its purification to a degree permitting its safe administration to type 1 diabetic patients were accomplished 100 years ago at the University of Toronto by Banting, Best, Collip and McLeod and constitute undeniably one of the major medical therapeutic revolutions, recognized by the attribution of the 1923 Nobel Prize in Physiology or Medicine to Banting and McLeod. The clinical spin off was immediate as well as the internationalization of insulin's commercial production. The outcomes regarding basic research were much slower, in particular regarding the molecular mechanisms of insulin action on its target cells. It took almost a half-century before the determination of the tri-dimensional structure of insulin in 1969 and the characterization of its cell receptor in 1970-1971. The demonstration that the insulin receptor is in fact an enzyme named tyrosine kinase came in the years 1982-1985, and the crystal structure of the intracellular kinase domain 10 years later. The crystal structure of the first intracellular kinase substrate (IRS-1) in 1991 paved the way for the elucidation of the intracellular signalling pathways but it took 15 more years to obtain the complete crystal structure of the extracellular receptor domain (without insulin) in 2006. Since then, the determination of the structure of the whole insulin-receptor complex in both the inactive and activated states has made considerable progress, not least due to recent improvement in the resolution power of cryo-electron microscopy. I will here review the steps in the development of the concept of hormone receptor, and of our knowledge of the structure and molecular mechanism of activation of the insulin receptor.
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Affiliation(s)
- Pierre De Meyts
- de Duve Institute, Department of Cell Signalling, Avenue Hippocrate 74, B-1200 Bruxelles, Belgique - Novo Nordisk A/S, Department of Stem Cell Research, Novo Nordisk Park 1, DK-2760 Maaloev, Danemark
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9
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Okawa MC, Cochran E, Lightbourne M, Brown RJ. Long-Term Effects of Metreleptin in Rabson-Mendenhall Syndrome on Glycemia, Growth, and Kidney Function. J Clin Endocrinol Metab 2022; 107:e1032-e1046. [PMID: 34718628 PMCID: PMC8852213 DOI: 10.1210/clinem/dgab782] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Rabson-Mendenhall syndrome (RMS) is caused by biallelic pathogenic variants in the insulin receptor gene (INSR) leading to insulin-resistant diabetes, microvascular complications, and growth hormone resistance with short stature. Small, uncontrolled studies suggest that 1-year treatment with recombinant leptin (metreleptin) improves glycemia in RMS. OBJECTIVE This study aimed to determine effects of long-term metreleptin in RMS on glycemia, anthropometrics, the growth hormone axis, and kidney function. METHODS We compared RMS patients during nonrandomized open-label treatment with metreleptin (≥ 0.15 mg/kg/day) vs no metreleptin over 90 months (5 subjects in both groups at different times, 4 only in metreleptin group, 2 only in control group). Main outcome measures were A1c; glucose; insulin; 24-hour urine glucose; standard deviation scores (SDS) for height, weight, body mass index (BMI), and insulin-like growth factor 1 (IGF-1); growth hormone; and estimated glomerular filtration rate. RESULTS Over time, metreleptin-treated subjects maintained 1.8 percentage point lower A1c vs controls (P = 0.007), which remained significant after accounting for changes in insulin doses. Metreleptin-treated subjects had a reduction in BMI SDS, which predicted decreased A1c. Growth hormone increased after metreleptin treatment vs control, with no difference in SDS between groups for IGF-1 or height. Reduced BMI predicted higher growth hormone, while reduced A1c predicted higher IGF-1. CONCLUSION Metreleptin alters the natural history of rising A1c in RMS, leading to lower A1c throughout long-term follow-up. Improved glycemia with metreleptin is likely attributable to appetite suppression and lower BMI SDS. Lower BMI after metreleptin may also worsen growth hormone resistance in RMS, resulting in a null effect on IGF-1 and growth despite improved glycemia.
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Affiliation(s)
- Marinna C Okawa
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Elaine Cochran
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Marissa Lightbourne
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Rebecca J Brown
- Diabetes, Endocrinology, and Obesity Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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Is type 2 diabetes an adiposity-based metabolic disease? From the origin of insulin resistance to the concept of dysfunctional adipose tissue. Eat Weight Disord 2021; 26:2429-2441. [PMID: 33555509 PMCID: PMC8602224 DOI: 10.1007/s40519-021-01109-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/12/2021] [Indexed: 12/13/2022] Open
Abstract
In the last decades of the past century, a remarkable amount of research efforts, money and hopes was generated to unveil the basis of insulin resistance that was believed to be the primary etiological factor in the development of type 2 diabetes. From the Reaven's insulin resistance syndrome to the DeFronzo's triumvirate (skeletal muscle, liver and beta-cell) and to Kahn's discovery (among many others) of insulin receptor downregulation and autophosphorylation, an enthusiastic age of metabolic in vivo and in vitro research took place, making the promise of a resolutory ending. However, from many published data (those of insulin receptoropathies and lipodystrophies, the genome-wide association studies results, the data on reversibility of type 2 diabetes after bariatric surgery or very-low-calorie diets, and many others) it appears that insulin resistance is not a primary defect but it develops secondarily to increased fat mass. In particular, it develops from a mismatch between the surplus caloric intake and the storage capacity of adipose tissue. On this basis, we propose to change the today's definition of type 2 diabetes in adiposity-based diabetes.Level of Evidence as a narrative review a vast array of studies have been included in the analysis, ranging from properly designed randomized controlled trials to case studies; however, the overall conclusion may be regarded as level IV.
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11
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Liguori F, Mascolo E, Vernì F. The Genetics of Diabetes: What We Can Learn from Drosophila. Int J Mol Sci 2021; 22:ijms222011295. [PMID: 34681954 PMCID: PMC8541427 DOI: 10.3390/ijms222011295] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/12/2021] [Accepted: 10/16/2021] [Indexed: 12/14/2022] Open
Abstract
Diabetes mellitus is a heterogeneous disease characterized by hyperglycemia due to impaired insulin secretion and/or action. All diabetes types have a strong genetic component. The most frequent forms, type 1 diabetes (T1D), type 2 diabetes (T2D) and gestational diabetes mellitus (GDM), are multifactorial syndromes associated with several genes’ effects together with environmental factors. Conversely, rare forms, neonatal diabetes mellitus (NDM) and maturity onset diabetes of the young (MODY), are caused by mutations in single genes. Large scale genome screenings led to the identification of hundreds of putative causative genes for multigenic diabetes, but all the loci identified so far explain only a small proportion of heritability. Nevertheless, several recent studies allowed not only the identification of some genes as causative, but also as putative targets of new drugs. Although monogenic forms of diabetes are the most suited to perform a precision approach and allow an accurate diagnosis, at least 80% of all monogenic cases remain still undiagnosed. The knowledge acquired so far addresses the future work towards a study more focused on the identification of diabetes causal variants; this aim will be reached only by combining expertise from different areas. In this perspective, model organism research is crucial. This review traces an overview of the genetics of diabetes and mainly focuses on Drosophila as a model system, describing how flies can contribute to diabetes knowledge advancement.
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Affiliation(s)
- Francesco Liguori
- Preclinical Neuroscience, IRCCS Santa Lucia Foundation, 00143 Rome, Italy;
| | - Elisa Mascolo
- Department of Biology and Biotechnology “Charles Darwin”, Sapienza University, 00185 Rome, Italy;
| | - Fiammetta Vernì
- Department of Biology and Biotechnology “Charles Darwin”, Sapienza University, 00185 Rome, Italy;
- Correspondence:
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12
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Abdelalim EM. Modeling different types of diabetes using human pluripotent stem cells. Cell Mol Life Sci 2021; 78:2459-2483. [PMID: 33242105 PMCID: PMC11072720 DOI: 10.1007/s00018-020-03710-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/19/2020] [Accepted: 11/11/2020] [Indexed: 12/22/2022]
Abstract
Diabetes mellitus (DM) is a metabolic disease characterized by chronic hyperglycemia as a result of progressive loss of pancreatic β cells, which could lead to several debilitating complications. Different paths, triggered by several genetic and environmental factors, lead to the loss of pancreatic β cells and/or function. Understanding these many paths to β cell damage or dysfunction could help in identifying therapeutic approaches specific for each path. Most of our knowledge about diabetes pathophysiology has been obtained from studies on animal models, which do not fully recapitulate human diabetes phenotypes. Currently, human pluripotent stem cell (hPSC) technology is a powerful tool for generating in vitro human models, which could provide key information about the disease pathogenesis and provide cells for personalized therapies. The recent progress in generating functional hPSC-derived β cells in combination with the rapid development in genomic and genome-editing technologies offer multiple options to understand the cellular and molecular mechanisms underlying the development of different types of diabetes. Recently, several in vitro hPSC-based strategies have been used for studying monogenic and polygenic forms of diabetes. This review summarizes the current knowledge about different hPSC-based diabetes models and how these models improved our current understanding of the pathophysiology of distinct forms of diabetes. Also, it highlights the progress in generating functional β cells in vitro, and discusses the current challenges and future perspectives related to the use of the in vitro hPSC-based strategies.
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Affiliation(s)
- Essam M Abdelalim
- Diabetes Research Center, Qatar Biomedical Research Institute (QBRI), Hamad Bin Khalifa University (HBKU), Qatar Foundation (QF), PO Box 34110, Doha, Qatar.
- College of Health and Life Sciences, Hamad Bin Khalifa University (HBKU), Qatar Foundation (QF), Education City, Doha, Qatar.
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A New Mutation of the INSR Gene in a 13-Year-Old Girl with Severe Insulin Resistance Syndrome in China. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8878149. [PMID: 33728347 PMCID: PMC7935593 DOI: 10.1155/2021/8878149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/18/2020] [Accepted: 02/18/2021] [Indexed: 11/18/2022]
Abstract
Background Mutations in insulin receptor genes can cause severe insulin resistance syndrome. Compared with Rabson-Mendenhall Syndrome and Donohue's Syndrome, type A insulin resistance syndrome is generally not serious. The main manifestations in woman with type A insulin resistance syndrome are hyperinsulinemia, insulin resistance, acanthosis nigricans, hyperandrogenism, and polycystic ovary. Case Presentation. A 13-year-old girl (Han nationality) visited the hospital due to hairiness and acanthosis nigricans. Further examination revealed severe hyperinsulinemia, insulin resistance, elevated blood glucose, hyperandrogenism, and polycystic ovary. Analysis of the insulin receptor gene by sequencing showed the presence of a nucleotide change in intron 7 (c. 1610+1G > A). The mutation was a splicing mutation, which can obviously affect the mRNA splicing of the insulin receptor and cause its function loss. The patient was finally diagnosed with type A insulin resistance syndrome. After 2 months of metformin treatment, the patient had spontaneous menstrual cramps and significantly improved acanthosis nigricans and sex hormones. Conclusion We report for the first time a new splicing mutation on the insulin receptor gene at the 7th intron (c.1610+1G > A), which leads to type A insulin resistance syndrome. In clinically suspected patients with polycystic ovary syndrome, if there are extremely high blood levels of insulin in the blood, genetic testing should be performed to detect insulin receptor gene mutation of type A insulin resistance syndrome.
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14
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Zhou Q, Yu J, Yuan X, Wang C, Zhu Z, Zhang A, Gu W. Clinical and Functional Characterization of Novel INSR Variants in Two Families With Severe Insulin Resistance Syndrome. Front Endocrinol (Lausanne) 2021; 12:606964. [PMID: 33995269 PMCID: PMC8117416 DOI: 10.3389/fendo.2021.606964] [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: 09/16/2020] [Accepted: 04/12/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Defects in the insulin receptor (INSR) gene cause various severe insulin resistance conditions, including Donohue syndrome (DS), Rabson-Mendenhall syndrome (RMS) and type A insulin resistance (type A-IR). This study aimed to investigate the clinical characterization and molecular defects in three Chinese children with INSR-related insulin resistance syndrome. METHODS We reviewed the clinical data of three Chinese children with INSR-related insulin resistance syndrome from two unrelated kindreds. Genetic analysis was performed using whole-exome sequencing and the effects of the novel variants were further assessed by in vitro functional assays. RESULTS The proband with type A-IR presented with acanthosis nigricans, hypertrichosis, and euglycemia with mild insulin resistance in early childhood. His sister presented with features typical of type A-IR and was diagnosed with diabetes mellitus with severe insulin resistance at the age of 9.8 years. The proband with DS showed typical dysmorphic characteristics, severe intrauterine growth retardation, extreme insulin resistance, fasting hypoglycemia and postprandial hyperglycemia from birth. The heterozygote variants c.[3670G>A]; c.[3614C>T] were identified in both siblings with type A-IR; and c.[749_751del]; c.[3355C>T] in the patient with DS. In vitro studies showed that the novel variant c.749_751del [p.(Thr250del)] in the α-subunit, reduced expression of the mature INSR protein and severely impaired INSR function. In contrast, the novel variant c.3670G>A [p.(Val1224Met)] in the β-subunit had no effect on total protein expression and phosphorylation of INSR and Akt, suggesting that the variant p.Val1224Met appeared to be tolerated and was not responsible for the severe insulin resistance. CONCLUSION Our study detailed the clinical features of three patients with type A-IR and DS, and identified two novel variants in the INSR gene. Functional assays indicated the novel variant p.Thr250del was pathogenic. In contrast, the novel variant p.Val1224Met was suggested to be tolerated by our experimental data, even though bioinformatics analyses predicted the variant as deleterious.
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Affiliation(s)
- Qiaoli Zhou
- Department of Endocrinology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Yu
- Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Xuewen Yuan
- Department of Endocrinology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Chunli Wang
- Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Ziyang Zhu
- Department of Endocrinology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Aihua Zhang
- Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, China
- Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
- *Correspondence: Wei Gu, ; Aihua Zhang,
| | - Wei Gu
- Department of Endocrinology, Children’s Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Wei Gu, ; Aihua Zhang,
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Brierley GV, Webber H, Rasijeff E, Grocott S, Siddle K, Semple RK. Anti-Insulin Receptor Antibodies Improve Hyperglycemia in a Mouse Model of Human Insulin Receptoropathy. Diabetes 2020; 69:2481-2489. [PMID: 32816962 PMCID: PMC7576564 DOI: 10.2337/db20-0345] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/11/2020] [Indexed: 02/07/2023]
Abstract
Loss-of-function mutations in both alleles of the human insulin receptor gene (INSR) cause extreme insulin resistance (IR) and usually death in childhood, with few effective therapeutic options. Bivalent antireceptor antibodies can elicit insulin-like signaling by mutant INSR in cultured cells, but whether this translates into meaningful metabolic benefits in vivo, wherein the dynamics of insulin signaling and receptor recycling are more complex, is unknown. To address this, we adopted a strategy to model human insulin receptoropathy in mice, using Cre recombinase delivered by adeno-associated virus to knockout endogenous hepatic Insr acutely in floxed Insr mice (liver insulin receptor knockout [L-IRKO] + GFP), before adenovirus-mediated add back of wild-type (WT) or mutant human INSR Two murine anti-INSR monoclonal antibodies, previously shown to be surrogate agonists for mutant INSR, were then tested by intraperitoneal injections. As expected, L-IRKO + GFP mice showed glucose intolerance and severe hyperinsulinemia. This was fully corrected by add back of WT but not with either D734A or S350L mutant INSR. Antibody injection improved glucose tolerance in D734A INSR-expressing mice and reduced hyperinsulinemia in both S350L and D734A INSR-expressing animals. It did not cause hypoglycemia in WT INSR-expressing mice. Antibody treatment also downregulated both WT and mutant INSR protein, attenuating its beneficial metabolic effects. Anti-INSR antibodies thus improve IR in an acute model of insulin receptoropathy, but these findings imply a narrow therapeutic window determined by competing effects of antibodies to stimulate receptors and induce their downregulation.
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Affiliation(s)
- Gemma V Brierley
- The University of Cambridge Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, U.K.
| | - Hannah Webber
- MRC Disease Model Core, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, U.K
| | - Eerika Rasijeff
- MRC Disease Model Core, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, U.K
| | - Sarah Grocott
- MRC Disease Model Core, Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, U.K
| | - Kenneth Siddle
- The University of Cambridge Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, U.K
| | - Robert K Semple
- The University of Cambridge Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, U.K.
- University of Edinburgh Centre for Cardiovascular Science, Queen's Medical Research Institute, Edinburgh, U.K
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16
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López Alaminos ME, Alvarado Rosas KA, Martinez Garcia M, Trincado Aznar P, Alvarez Ballano D. Resistencia a la insulina tipo A, nueva mutación del gen del receptor de la insulina descrita. ENDOCRINOL DIAB NUTR 2020; 67:611-612. [DOI: 10.1016/j.endinu.2019.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/11/2019] [Accepted: 11/13/2019] [Indexed: 10/24/2022]
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17
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Kushi R, Hirota Y, Ogawa W. Insulin resistance and exaggerated insulin sensitivity triggered by single-gene mutations in the insulin signaling pathway. Diabetol Int 2020; 12:62-67. [PMID: 33479580 DOI: 10.1007/s13340-020-00455-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Indexed: 12/12/2022]
Abstract
Whereas the genetic basis of insulin sensitivity is determined by variation in multiple genes, mutations of single genes can give rise to profound changes in such sensitivity. Mutations of the insulin receptor gene (INSR)-which trigger type A insulin resistance, Rabson-Mendenhall, or Donohue syndromes-and those of the gene for the p85α regulatory subunit of phosphoinositide 3-kinase (PIK3R1), which give rise to SHORT syndrome, are the most common and second most common causes, respectively, of single-gene insulin resistance. Loss-of-function mutations of the genes for the protein kinase Akt2 (AKT2) or for TBC1 domain family member 4 (TBC1D4) have been identified in families with severe insulin resistance. Gain-of-function mutations of the gene for protein tyrosine phosphatase nonreceptor type 11 (PTPN11), which negatively regulates insulin receptor signaling, give rise to Noonan syndrome, and some individuals with this syndrome manifest insulin resistance. Gain-of-function mutations of the gene for the p110α catalytic subunit of phosphoinositide 3-kinase (PIK3CA) have been identified in individuals with segmental overgrowth or megalencephaly, some of whom also manifest spontaneous hypoglycemia. A gain-of-function mutation of AKT2 was also found in individuals with recurrent hypoglycemia. Loss-of-function mutations of the gene for phosphatase and tensin homolog (PTEN), another negative regulator of insulin signaling, give rise to Cowden syndrome in association with exaggerated metabolic actions of insulin. Clinical manifestations of individuals with such mutations of genes related to insulin signaling thus provide insight into the essential function of such genes in the human body.
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Affiliation(s)
- Ryo Kushi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017 Japan
| | - Yushi Hirota
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017 Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-cho, Chuo-ku, Kobe, 650-0017 Japan
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Ibáñez L, Oberfield SE, Witchel S, Auchus RJ, Chang RJ, Codner E, Dabadghao P, Darendeliler F, Elbarbary NS, Gambineri A, Garcia Rudaz C, Hoeger KM, López-Bermejo A, Ong K, Peña AS, Reinehr T, Santoro N, Tena-Sempere M, Tao R, Yildiz BO, Alkhayyat H, Deeb A, Joel D, Horikawa R, de Zegher F, Lee PA. An International Consortium Update: Pathophysiology, Diagnosis, and Treatment of Polycystic Ovarian Syndrome in Adolescence. Horm Res Paediatr 2018; 88:371-395. [PMID: 29156452 DOI: 10.1159/000479371] [Citation(s) in RCA: 206] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 07/10/2017] [Indexed: 12/11/2022] Open
Abstract
This paper represents an international collaboration of paediatric endocrine and other societies (listed in the Appendix) under the International Consortium of Paediatric Endocrinology (ICPE) aiming to improve worldwide care of adolescent girls with polycystic ovary syndrome (PCOS)1. The manuscript examines pathophysiology and guidelines for the diagnosis and management of PCOS during adolescence. The complex pathophysiology of PCOS involves the interaction of genetic and epigenetic changes, primary ovarian abnormalities, neuroendocrine alterations, and endocrine and metabolic modifiers such as anti-Müllerian hormone, hyperinsulinemia, insulin resistance, adiposity, and adiponectin levels. Appropriate diagnosis of adolescent PCOS should include adequate and careful evaluation of symptoms, such as hirsutism, severe acne, and menstrual irregularities 2 years beyond menarche, and elevated androgen levels. Polycystic ovarian morphology on ultrasound without hyperandrogenism or menstrual irregularities should not be used to diagnose adolescent PCOS. Hyperinsulinemia, insulin resistance, and obesity may be present in adolescents with PCOS, but are not considered to be diagnostic criteria. Treatment of adolescent PCOS should include lifestyle intervention, local therapies, and medications. Insulin sensitizers like metformin and oral contraceptive pills provide short-term benefits on PCOS symptoms. There are limited data on anti-androgens and combined therapies showing additive/synergistic actions for adolescents. Reproductive aspects and transition should be taken into account when managing adolescents.
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Affiliation(s)
- Lourdes Ibáñez
- Endocrinology, Hospital Sant Joan de Deu, Esplugues, Barcelona, Spain.,CIBERDEM, ISCIII, Madrid, Spain
| | - Sharon E Oberfield
- Division of Pediatric Endocrinology, CUMC, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Selma Witchel
- Division of Pediatric Endocrinology, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | | | - R Jeffrey Chang
- Department of Reproductive Medicine, UCSD School of Medicine, La Jolla, California, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, University of Chile, School of Medicine, Santiago, Chile
| | - Preeti Dabadghao
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | - Alessandra Gambineri
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Cecilia Garcia Rudaz
- Division of Women, Youth and Children, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Kathleen M Hoeger
- Department of OBGYN, University of Rochester Medical Center, Rochester, New York, USA
| | - Abel López-Bermejo
- Pediatric Endocrinology, Hospital de Girona Dr. Josep Trueta, Girona, Spain
| | - Ken Ong
- MRC Epidemiology Unit, University of Cambridge, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Alexia S Peña
- The University of Adelaide and Robinson Research Institute, Adelaide, South Australia, Australia
| | - Thomas Reinehr
- University of Witten/Herdecke, Vestische Kinder- und Jugendklinik, Pediatric Endocrinology, Diabetes, and Nutrition Medicine, Datteln, Germany
| | - Nicola Santoro
- Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Rachel Tao
- Division of Pediatric Endocrinology, CUMC, New York-Presbyterian Morgan Stanley Children's Hospital, New York, New York, USA
| | - Bulent O Yildiz
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Hacettepe University School of Medicine, Ankara, Turkey
| | - Haya Alkhayyat
- Medical University of Bahrain, BDF Hospital, Riffa, Bahrein
| | - Asma Deeb
- Mafraq Hospital, Abu Dhabi, United Arab Emirates
| | - Dipesalema Joel
- Department of Paediatrics and Adolescent Health, University of Botswana Teaching Hospital, Gaborone, Botswana
| | - Reiko Horikawa
- Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Francis de Zegher
- Department Pediatrics, University Hospital Gasthuisberg, Leuven, Belgium
| | - Peter A Lee
- Department of Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania, USA
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Crespo RP, Bachega TASS, Mendonça BB, Gomes LG. An update of genetic basis of PCOS pathogenesis. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2018; 62:352-361. [PMID: 29972435 PMCID: PMC10118782 DOI: 10.20945/2359-3997000000049] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/30/2018] [Indexed: 02/07/2023]
Abstract
Polycystic ovary syndrome (PCOS) is a common and complex endocrine disorder that affects 5-20% of reproductive age women. PCOS clinical symptoms include hirsutism, menstrual dysfunction, infertility, obesity and metabolic syndrome. There is a wide heterogeneity in clinical manifestations and metabolic complications. The pathogenesis of PCOS is not fully elucidated, but four aspects seem to contribute to the syndrome to different degrees: increased ovarian and/or adrenal androgen secretion, partial folliculogenesis arrest, insulin resistance and neuroendocrine axis dysfunction. A definitive etiology remains to be elucidated, but PCOS has a strong heritable component indicated by familial clustering and twin studies. Genome Wide Association Studies (GWAS) have identified several new risk loci and candidate genes for PCOS. Despite these findings, the association studies have explained less than 10% of heritability. Therefore, we could speculate that different phenotypes and subphenotypes are caused by rare private genetic variants. Modern genetic studies, such as whole exome and genome sequencing, will help to clarify the contribution of these rare genetic variants on different PCOS phenotypes. Arch Endocrinol Metab. 2018;62(3):352-61.
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Affiliation(s)
- Raiane P Crespo
- Divisão de Endocrinologia e Laboratório de Hormônios e Genética Molecular (LIM-42), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Tania A S S Bachega
- Divisão de Endocrinologia e Laboratório de Hormônios e Genética Molecular (LIM-42), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Berenice B Mendonça
- Divisão de Endocrinologia e Laboratório de Hormônios e Genética Molecular (LIM-42), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
| | - Larissa G Gomes
- Divisão de Endocrinologia e Laboratório de Hormônios e Genética Molecular (LIM-42), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP, Brasil
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20
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Brierley GV, Siddle K, Semple RK. Evaluation of anti-insulin receptor antibodies as potential novel therapies for human insulin receptoropathy using cell culture models. Diabetologia 2018; 61:1662-1675. [PMID: 29700562 PMCID: PMC6445487 DOI: 10.1007/s00125-018-4606-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 03/06/2018] [Indexed: 12/28/2022]
Abstract
AIMS/HYPOTHESIS Bi-allelic loss-of-function mutations in the INSR gene (encoding the insulin receptor [INSR]) commonly cause extreme insulin resistance and early mortality. Therapeutic options are limited, but anti-INSR antibodies have been shown to activate two mutant receptors, S323L and F382V. This study evaluates four well-characterised murine anti-INSR monoclonal antibodies recognising distinct epitopes (83-7, 83-14, 18-44, 18-146) as surrogate agonists for potential targeted treatment of severe insulin resistance arising from insulin receptoropathies. METHODS Ten naturally occurring mutant human INSRs with defects affecting different aspects of receptor function were modelled and assessed for response to insulin and anti-INSR antibodies. A novel 3T3-L1 adipocyte model of insulin receptoropathy was generated, permitting conditional knockdown of endogenous mouse Insr by lentiviral expression of species-specific short hairpin (sh)RNAs with simultaneous expression of human mutant INSR transgenes. RESULTS All expressed mutant INSR bound to all antibodies tested. Eight mutants showed antibody-induced autophosphorylation, while co-treatment with antibody and insulin increased maximal phosphorylation compared with insulin alone. After knockdown of mouse Insr and expression of mutant INSR in 3T3-L1 adipocytes, two antibodies (83-7 and 83-14) activated signalling via protein kinase B (Akt) preferentially over signalling via extracellular signal-regulated kinase 1/2 (ERK1/2) for seven mutants. These antibodies stimulated glucose uptake via P193L, S323L, F382V and D707A mutant INSRs, with antibody response greater than insulin response for D707A. CONCLUSIONS/INTERPRETATION Anti-INSR monoclonal antibodies can activate selected naturally occurring mutant human insulin receptors, bringing closer the prospect of novel therapy for severe insulin resistance caused by recessive mutations.
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Affiliation(s)
- Gemma V Brierley
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
- National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Kenneth Siddle
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
- National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Robert K Semple
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK.
- National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK.
- University of Edinburgh Centre for Cardiovascular Science, Queen's Medical Research Institute, Little France Crescent, Edinburgh, EH16 4TJ, UK.
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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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Caenorhabditis elegans DAF-2 as a Model for Human Insulin Receptoropathies. G3-GENES GENOMES GENETICS 2017; 7:257-268. [PMID: 27856697 PMCID: PMC5217114 DOI: 10.1534/g3.116.037184] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Human exome sequencing has dramatically increased the rate of identification of disease-associated polymorphisms. However, examining the functional consequences of those variants has created an analytic bottleneck. Insulin-like signaling in Caenorhabditis elegans has long provided a model to assess consequences of human insulin signaling mutations, but this has not been evaluated in the context of current genetic tools. We have exploited strains derived from the Million Mutation Project (MMP) and gene editing to explore further the evolutionary relationships and conservation between the human and C. elegans insulin receptors. Of 40 MMP alleles analyzed in the C. elegans insulin-like receptor gene DAF-2, 35 exhibited insulin-like signaling indistinguishable from wild-type animals, indicating tolerated mutations. Five MMP alleles proved to be novel dauer-enhancing mutations, including one new allele in the previously uncharacterized C-terminus of DAF-2. CRISPR-Cas9 genome editing was used to confirm the phenotypic consequence of six of these DAF-2 mutations and to replicate an allelic series of known human disease mutations in a highly conserved tyrosine kinase active site residue, demonstrating the utility of C. elegans for directly modeling human disease. Our results illustrate the challenges associated with prediction of the phenotypic consequences of amino acid substitutions, the value of assaying mutant isoform function in vivo, and how recently developed tools and resources afford the opportunity to expand our understanding even of highly conserved regulatory modules such as insulin signaling. This approach may prove generally useful for modeling phenotypic consequences of candidate human pathogenic mutations in conserved signaling and developmental pathways.
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Zhao H, Lv Y, Li L, Chen ZJ. Genetic Studies on Polycystic Ovary Syndrome. Best Pract Res Clin Obstet Gynaecol 2016; 37:56-65. [DOI: 10.1016/j.bpobgyn.2016.04.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 03/21/2016] [Accepted: 04/19/2016] [Indexed: 01/19/2023]
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Semple RK. EJE PRIZE 2015: How does insulin resistance arise, and how does it cause disease? Human genetic lessons. Eur J Endocrinol 2016; 174:R209-23. [PMID: 26865583 DOI: 10.1530/eje-15-1131] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 02/09/2016] [Indexed: 12/25/2022]
Abstract
Insulin orchestrates physiological responses to ingested nutrients; however, although it elicits widely ramifying metabolic and trophic responses from diverse tissues, 'insulin resistance (IR)', a pandemic metabolic derangement commonly associated with obesity, is usually defined solely by blunting of insulin's hypoglycaemic effect. Recent study of monogenic forms of IR has established that biochemical subphenotypes of IR exist, clustering into those caused by primary disorders of adipose tissue and those caused by primary defects in proximal insulin signalling. IR is often first recognised by virtue of its associated disorders including type 2 diabetes, dyslipidaemia (DL), fatty liver and polycystic ovary syndrome (PCOS). Although these clinically observed associations are confirmed by cross-sectional and longitudinal population-based studies, causal relationships among these phenomena have been more difficult to establish. Single gene IR is important to recognise in order to optimise clinical management and also permits testing of causal relationships among components of the IR syndrome using the principle of Mendelian randomisation. Thus, where a precisely defined genetic defect is identified that directly produces one component of the syndrome, then phenomena that are causally linked to that component should be seen. Where this is not the case, then a simple causal link is refuted. This article summarises known forms of monogenic severe IR and considers the lessons to be learned about the pathogenic mechanisms both upstream from common IR and those downstream linking it to disorders such as DL, fatty liver, PCOS and cancer.
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Affiliation(s)
- R K Semple
- University of Cambridge Metabolic Research LaboratoriesWellcome Trust-MRC Institute of Metabolic Science, Level 4, Box 289, Addenbrooke's Treatment Centre, Cambridge CB2 OQQ, UK
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25
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Abstract
CONTEXT Polycystic ovary syndrome (PCOS) is a common complex genetic disease. It is characterized by hyperandrogenism, gonadotropin secretory changes, polycystic ovarian morphology, and insulin resistance. The etiology of PCOS remains unknown, but modern genetic approaches, such as genome-wide association studies (GWAS), Mendelian randomization, and next-generation sequencing, promise to identify the pathways that are primarily disrupted. EVIDENCE ACQUISITION The literature on PCOS, including the author's research, is discussed. EVIDENCE SYNTHESIS Recent genetic analyses are reviewed. CONCLUSIONS Considerable progress has been made mapping PCOS susceptibility genes. GWAS have implicated gonadotropin secretion and action as important primary defects in disease pathogenesis in European and Han Chinese PCOS cohorts, respectively. European women with the National Institutes of Health and Rotterdam phenotypes as well as those with self-reported PCOS have some gene regions in common, such as chromosome 11p14.1 region containing the FSH B polypeptide (FSHB) gene, suggesting shared genetic susceptibility. Several chromosomal signals are significant in both Han Chinese and European PCOS cohorts, suggesting that the susceptibility genes in these regions are evolutionarily conserved. In addition, GWAS have suggested that DENND1A, epidermal growth factor signaling, and DNA repair pathways play a role in PCOS pathogenesis. Only a small amount of the heritability of PCOS is accounted for by the common susceptibility variants mapped so far. Future studies should clarify the contribution of rare genetic variants and epigenetic factors to the PCOS phenotype. Furthermore, Mendelian randomization can be used to clarify causal relationships, and phenome-wide association studies can provide insight into health risks associated with PCOS susceptibility variants.
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Affiliation(s)
- Andrea Dunaif
- Division of Endocrinology, Metabolism, and Molecular Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611
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26
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Obesity and cancer, a case for insulin signaling. Cell Death Dis 2015; 6:e2037. [PMID: 26720346 PMCID: PMC4720912 DOI: 10.1038/cddis.2015.381] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 11/24/2015] [Accepted: 11/26/2015] [Indexed: 02/08/2023]
Abstract
Obesity is a worldwide epidemic, with the number of overweight and obese individuals climbing from just over 500 million in 2008 to 1.9 billion in 2014. Type 2 diabetes (T2D), cardiovascular disease and non-alcoholic fatty liver disease have long been associated with the obese state, whereas cancer is quickly emerging as another pathological consequence of this disease. Globally, at least 2.8 million people die each year from being overweight or obese. It is estimated that by 2020 being overweight or obese will surpass the health burden of tobacco consumption. Increase in the body mass index (BMI) in overweight (BMI>25 kg/m2) and obese (BMI>30 kg/m2) individuals is a result of adipose tissue (AT) expansion, which can lead to fat comprising >50% of the body weight in the morbidly obese. Extensive research over the last several years has painted a very complex picture of AT biology. One clear link between AT expansion and etiology of diseases like T2D and cancer is the development of insulin resistance (IR) and hyperinsulinemia. This review focuses on defining the link between obesity, IR and cancer.
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Rabbone I, Galderisi A, Tinti D, Ignaccolo MG, Barbetti F, Cerutti F. Case Report: When an Induced Illness Looks Like a Rare Disease. Pediatrics 2015; 136:e1361-5. [PMID: 26438710 DOI: 10.1542/peds.2014-4165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2015] [Indexed: 11/24/2022] Open
Abstract
The recognition of fabricated illness (FI) in a child represents a diagnostic challenge. The suspicion of FI often arises from the discrepancy between laboratory tests and clinical history. For instance, (unnecessary) insulin injections by caregivers has been widely described as a common cause of factitious hypoglycemia that may be inferred from discrepancies between plasma insulin and c-peptide. However, contemporary administration of insulin with an insulin secretagogue (glyburide), and of additional drugs, can make the diagnostic pathway problematic. We report the case of a child 4 years and 11 months old, admitted for alternance of hypo- and hyperglycemia associated with hirsutism, hypokalemia, nephrocalcinosis, and neurodevelopmental delay. All these features were compatible with Rabson-Mendenhall syndrome, a rare disorder of severe insulin resistance linked to mutations of insulin receptor. At admission, plasma insulin levels were high during hypoglycemic episodes, but c-peptide was repeatedly in the normal range. The genetic analysis of insulin receptor was negative. The story of previous hospital admissions, inconsistency between insulin and c-peptide values, and association between hypoglycemic episodes in the child with the presence of the mother, raised the suspicion of FI. This hypothesis was confirmed by a video recording that revealed the administration by the mother of multiple drugs (insulin, glyburide, progesterone, and furosemide) that mimicked most of the features of Rabson-Mendenhall syndrome, including hirsutism and hypoglycemia with coincident, inappropriately normal c-peptide values due to the administration of the insulin secretagogue. Our case indicates that inconsistency among consecutive diagnostic tests should be regarded as a clue of FI.
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Affiliation(s)
- Ivana Rabbone
- Department of Pediatrics, University of Turin, Turin, Italy;
| | - Alfonso Galderisi
- Department of Women and Children's Health, University of Padua, Padua, Italy
| | - Davide Tinti
- Department of Pediatrics, University of Turin, Turin, Italy
| | | | - Fabrizio Barbetti
- Department of Experimental Medicine and Surgery, University of Tor Vergata, Rome, Italy; and Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Franco Cerutti
- Department of Pediatrics, University of Turin, Turin, Italy
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Enkhtuvshin B, Nagashima S, Saito N, Wakabayashi T, Ando A, Takahashi M, Sakai K, Yamamuro D, Nagasaka S, Tamemoto H, Ishibashi S. Successful pregnancy outcomes in a patient with type A insulin resistance syndrome. Diabet Med 2015; 32:e16-9. [PMID: 25472847 PMCID: PMC5034500 DOI: 10.1111/dme.12659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/01/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND The management of severe insulin resistance during pregnancy is challenging because of the increased risk of perinatal complications for both mother and fetus. We describe two consecutive pregnancies in a patient with severe insulin resistance caused by a mutation in the β subunit of the insulin receptor. CASE REPORT A non-obese Japanese woman was diagnosed as having diabetes mellitus during her first pregnancy at age 31 years. She presented at 6 weeks' gestation with a fasting plasma glucose concentration of 15.1 mmol/l and an HbA(1c) level of 95 mmol/mol (10.8%). Fasting insulin concentration was high at 68.8 μU/ml, suggesting severe insulin resistance. Anti-insulin and insulin-receptor antibodies were both negative. Genetic analysis revealed an in-frame heterozygous deletion mutation (∆Leu(999)) in the insulin receptor gene. Despite large daily doses (up to 480 units per day) of insulin aspart and isophane, the patient's postprandial plasma glucose level exceeded 11.1 mmol/l. In the patient's second pregnancy, the addition of metformin at a dose of 2250 mg per day achieved tighter glycaemic control, with lower doses of insulin lispro and isophane (up to 174 units/day). Both newborns, who were found to carry the same mutation, were small for gestational age and developed transient hypoglycaemia after birth. CONCLUSION Adding metformin to the conventional insulin regimen effectively achieved tight glycaemic control with a lower dose of insulin. The mutation of the insulin receptor gene might underlie the intrauterine growth retardation of the newborns. To our knowledge, this is the first report of successful management of diabetes mellitus in a pregnant woman with type A insulin resistance syndrome.
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Affiliation(s)
- B Enkhtuvshin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - S Nagashima
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - N Saito
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - T Wakabayashi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - A Ando
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - M Takahashi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - K Sakai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - D Yamamuro
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - S Nagasaka
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
| | - H Tamemoto
- Division of Medical Biochemistry, Department of Biochemistry, School of Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - S Ishibashi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Shimotsuke, Tochigi, Japan
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Roženková K, Güemes M, Shah P, Hussain K. The Diagnosis and Management of Hyperinsulinaemic Hypoglycaemia. J Clin Res Pediatr Endocrinol 2015; 7:86-97. [PMID: 26316429 PMCID: PMC4563192 DOI: 10.4274/jcrpe.1891] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Insulin secretion from pancreatic β-cells is tightly regulated to keep fasting blood glucose concentrations within the normal range (3.5-5.5 mmol/L). Hyperinsulinaemic hypoglycaemia (HH) is a heterozygous condition in which insulin secretion becomes unregulated and its production persists despite low blood glucose levels. It is the most common cause of severe and persistent hypoglycaemia in neonates and children. The most severe and permanent forms are due to congenital hyperinsulinism (CHI). Recent advances in genetics have linked CHI to mutations in 9 genes that play a key role in regulating insulin secretion (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A and HNF1A). Histologically, CHI can be divided into 3 types; diffuse, focal and atypical. Given the biochemical nature of HH (non-ketotic), a delay in the diagnosis and management can result in irreversible brain damage. Therefore, it is essential to diagnose and treat HH promptly. Advances in molecular genetics, imaging methods (18F-DOPA PET-CT), medical therapy and surgical approach (laparoscopic surgery) have completely changed the management and improved the outcome of these children. This review provides an overview of the genetic and molecular mechanisms leading to development of HH in children. The article summarizes the current diagnostic methods and management strategies for the different types of CHI.
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Affiliation(s)
| | | | | | - Khalid Hussain
- Great Ormond Street Hospital for Children, UCL Institute of Child Health, Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, London, UK Phone: +44 2079052128 E-mail:
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30
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Ros P, Colino-Alcol E, Grasso V, Barbetti F, Argente J. Síndrome de insulinorresistencia severa tipo A debido a mutación del gen del receptor de insulina. An Pediatr (Barc) 2015; 82:e30-4. [DOI: 10.1016/j.anpedi.2014.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 03/01/2014] [Accepted: 03/11/2014] [Indexed: 02/05/2023] Open
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Grandér D, Johnsson P. Pseudogene-Expressed RNAs: Emerging Roles in Gene Regulation and Disease. Curr Top Microbiol Immunol 2015; 394:111-26. [DOI: 10.1007/82_2015_442] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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32
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Iovino S, Burkart AM, Kriauciunas K, Warren L, Hughes KJ, Molla M, Lee YK, Patti ME, Kahn CR. Genetic insulin resistance is a potent regulator of gene expression and proliferation in human iPS cells. Diabetes 2014; 63:4130-42. [PMID: 25059784 PMCID: PMC4238001 DOI: 10.2337/db14-0109] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Insulin resistance is central to diabetes and metabolic syndrome. To define the consequences of genetic insulin resistance distinct from those secondary to cellular differentiation or in vivo regulation, we generated induced pluripotent stem cells (iPSCs) from individuals with insulin receptor mutations and age-appropriate control subjects and studied insulin signaling and gene expression compared with the fibroblasts from which they were derived. iPSCs from patients with genetic insulin resistance exhibited altered insulin signaling, paralleling that seen in the original fibroblasts. Insulin-stimulated expression of immediate early genes and proliferation were also potently reduced in insulin resistant iPSCs. Global gene expression analysis revealed marked differences in both insulin-resistant iPSCs and corresponding fibroblasts compared with control iPSCs and fibroblasts. Patterns of gene expression in patients with genetic insulin resistance were particularly distinct in the two cell types, indicating dependence on not only receptor activity but also the cellular context of the mutant insulin receptor. Thus, iPSCs provide a novel approach to define effects of genetically determined insulin resistance. This study demonstrates that effects of insulin resistance on gene expression are modified by cellular context and differentiation state. Moreover, altered insulin receptor signaling and insulin resistance can modify proliferation and function of pluripotent stem cell populations.
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Affiliation(s)
- Salvatore Iovino
- Integrative Physiology and Metabolism Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Alison M Burkart
- Integrative Physiology and Metabolism Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Kristina Kriauciunas
- Integrative Physiology and Metabolism Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Laura Warren
- Integrative Physiology and Metabolism Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Katelyn J Hughes
- Integrative Physiology and Metabolism Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Michael Molla
- Integrative Physiology and Metabolism Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Youn-Kyoung Lee
- Department of Stem Cell and Regenerative Biology, Harvard University, Cambridge, MA
| | - Mary-Elizabeth Patti
- Integrative Physiology and Metabolism Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - C Ronald Kahn
- Integrative Physiology and Metabolism Research Division, Joslin Diabetes Center, Harvard Medical School, Boston, MA
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Honardoost M, reza Sarookhani M, Arefian E, Soleimani M. Insulin Resistance Associated Genes and miRNAs. Appl Biochem Biotechnol 2014; 174:63-80. [DOI: 10.1007/s12010-014-1014-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 06/15/2014] [Indexed: 01/05/2023]
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34
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Lee J, Miyazaki M, Romeo GR, Shoelson SE. Insulin receptor activation with transmembrane domain ligands. J Biol Chem 2014; 289:19769-77. [PMID: 24867955 DOI: 10.1074/jbc.m114.578641] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Complementary surfaces are buried when peptide hormones, growth factors, or cytokines bind and activate cellular receptors. Although these extended surfaces provide high affinity and specificity to the interactions, they also present great challenges to the design of small molecules that might either mimic or antagonize the process. We show that the insulin receptor (IR) and downstream signals can be activated by targeting a site outside of its ligand-binding domain. A 24-residue peptide having the IR transmembrane (TM) domain sequence activates IR, but not related growth factor receptors, through specific interactions with the receptor TM domain. Like insulin-dependent activation, IR-TM requires that IR have a competent ATP-binding site and kinase activation loop. IR-TM also activates mutated receptors from patients with severe insulin resistance, which do not respond to insulin. These results show that IR can be activated through a pathway that bypasses its canonical ligand-binding domain.
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Affiliation(s)
- Jongsoon Lee
- From the Joslin Diabetes Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts 02215
| | - Masaya Miyazaki
- From the Joslin Diabetes Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts 02215
| | - Giulio R Romeo
- From the Joslin Diabetes Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts 02215
| | - Steven E Shoelson
- From the Joslin Diabetes Center and Department of Medicine, Harvard Medical School, Boston, Massachusetts 02215
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35
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Domínguez-García A, Martínez R, Urrutia I, Garin I, Castaño L. Identification of a novel insulin receptor gene heterozygous mutation in a patient with type A insulin resistance syndrome. J Pediatr Endocrinol Metab 2014; 27:561-4. [PMID: 24468607 DOI: 10.1515/jpem-2013-0284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 12/02/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Several types of mutations in the insulin receptor gene have been identified in patients with genetic syndromes of insulin resistance. PATIENT REPORT We describe a 12-year-old girl with type A insulin resistance with hyperandrogenism, hyperinsulinemia, and diabetes mellitus but without the dysmorphic characteristic of leprechaunism or Rabson-Mendenhall syndrome. The proband's mother had hyperinsulinemia and diabetes mellitus but did not show any common clinical features of type A insulin resistance. The proband's brother also had hyperinsulinemia but manifested neither glucose intolerance nor common clinical features of type A insulin resistance. A novel heterozygous mutation, p.Asn1164Thr, of the insulin receptor gene (INSR) was identified in this family. CONCLUSION These cases illustrate the diversity of clinical phenotypes associated with mutations of the insulin receptor gene.
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36
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Grasso V, Colombo C, Favalli V, Galderisi A, Rabbone I, Gombos S, Bonora E, Massa O, Meschi F, Cerutti F, Iafusco D, Bonfanti R, Monciotti C, Barbetti F. Six cases with severe insulin resistance (SIR) associated with mutations of insulin receptor: Is a Bartter-like syndrome a feature of congenital SIR? Acta Diabetol 2013; 50:951-7. [PMID: 23824322 DOI: 10.1007/s00592-013-0490-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 06/08/2013] [Indexed: 10/26/2022]
Abstract
Biallelic insulin receptor (INSR) gene mutations cause congenital syndromes of severe insulin resistance (SIR) known as Donohue syndrome (DS) and Rabson-Mendenhall syndrome (RMS). At presentation, DS and RMS are difficult to differentiate since they share many clinical features; however, while patients with DS usually die within 1 year of birth, individuals classified as RMS can reach adult age. INSR mutations can be also found in pubertal females with hyperinsulinism, hyperandrogenism, and acanthosis nigricans (type A SIR). We studied the INSR gene in five subjects with congenital SIR and in a patient with type A SIR. Nine biallelic INSR gene mutations (eight novels, including an in-frame deletion of INSR signal peptide) were identified in patients with congenital SIR; a heterozygous, spontaneous INSR mutation was detected in the patient with type A SIR. Two probands, presenting severe hirsutism at birth, died at the age of 3 months and were classified as DS, while other 2, currently 2 and 3 years old, were diagnosed with RMS (patients 3 and 4). The fifth patient with congenital SIR died when 14 months old. Nephrocalcinosis, hyperaldosteronism, hyperreninemia, and hypokalemia, in the absence of hypertension, were discovered in patients 3 and 5 when 24 and 4 months old, respectively. Patient 3, now 3 years/3 months old, still shows hyperreninemic hyperaldosteronism requiring potassium supplementation. We conclude that renal abnormalities resembling antenatal Bartter's syndrome type II, recently reported also by others, is a common observation in patients with congenital SIR.
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Affiliation(s)
- Valeria Grasso
- Laboratory of Mendelian Diabetes, Bambino Gesù Childrens' Hospital, Rome, Italy
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Fatchiyah F, Christian N, Soeatmadji D. Reducing IRS-1 Activation Cause Mutation of Tyrosine Kinase Domain hINSR Gene on Type-2 Diabetes Mellitus Patients. Bioinformation 2013; 9:853-7. [PMID: 24250111 PMCID: PMC3819570 DOI: 10.6026/97320630009853] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 09/30/2013] [Indexed: 11/23/2022] Open
Abstract
The purpose of this study is to examine the effect of mutation on tyrosine kinase hINSR gene of DM Type 2 patients reduce the IRS- 1 activation by in silico analysis. Blood DNA of DM Type 2 patients from Saeful Anwar Hospital Malang were amplified and sequenced by specific primers of tyrosine kinase domain of hINSR gene. These gene sequences were converted to protein sequence by BLAST and the IRS-1 protein sequence is retrieved from NCBI database. Both of the protein sequence was aligned by using Bio edit version 5.0.6. The model of three dimension protein was predicted by SWISS MODEL webserver, and visualized the structure alteration by using Pymol 0.99rc6 and Hex 5.0, and then superimpose of the hINSR and IRS-1 interaction were examined by docking using Hex 5.0. The results showed that one substitution and one deletion of 8-3F patient exon-22 hINSR gene tyrosine kinase domain cause loss of four helixes and three coils structures on tyrosine kinase hINSR protein. Six-deletions and six-substitutions on same gene domain of DMK9 patient changed the two helixes became coil structure. The binding energy of hINSR tyrosine kinase with IRS-1 of normal is E= -494.67 kJ/mol, DMK9 patient is E= -458.4 kJ/mol, and 8-3F patient is E=-544.20 kJ/mol. The DMK9 patient prognosis has better physiological condition than 8-3F patient. Interaction between 8-3F of hINSR tyrosine kinase domain mutation and PTB domain IRS-1 is more spontaneous than DMK9, but both of them were reduced on IRS-1 activation respectively.
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Affiliation(s)
- Fatchiyah Fatchiyah
- Department of Biology, Faculty of Mathematics and Natural Sciences, Brawijaya University, Jl Veteran, Malang, East Java 65145,Indonesia
| | - Nur Christian
- Department of Biology, Faculty of Mathematics and Natural Sciences, Brawijaya University, Jl Veteran, Malang, East Java 65145,Indonesia
| | - DjokoWahono Soeatmadji
- Department of Endocrinology, Saeful Anwar Hospital, Jl. Jaksa Agung Suprapto No. 2 Malang, East Java, Indonesia
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Hovnik T, Bratanič N, Podkrajšek KT, Kovač J, Paro D, Podnar T, Bratina N, Battelino T. Severe progressive obstructive cardiomyopathy and renal tubular dysfunction in Donohue syndrome with decreased insulin receptor autophosphorylation due to a novel INSR mutation. Eur J Pediatr 2013; 172:1125-9. [PMID: 23229189 DOI: 10.1007/s00431-012-1901-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 11/16/2012] [Accepted: 11/22/2012] [Indexed: 12/29/2022]
Abstract
UNLABELLED Donohue syndrome (leprechaunism; OMIM *246200) is a rare, recessively inherited disorder of extreme insulin resistance due to mutations in the insulin receptor gene (INSR) causing either defects in insulin binding or receptor autophosphorylation and tyrosine kinase activity. We report a patient with pronounced clinical picture of leprechaunism who developed severe progressive hypertrophic obstructive cardiomyopathy (HOCM) and renal tubular dysfunction which improved on continuous subcutaneous infusion of recombinant human insulin-like growth factor-1 (rhIGF-I). INSR gene molecular analysis and insulin receptor (IR) autophosphorylation on cultured fibroblasts were performed. A novel homozygous missense mutation p.Leu795Pro was found, located in the extracellular portion of the β subunit of the insulin receptor. The post-binding defect of the insulin receptor signaling in cultured fibroblasts demonstrated decreased insulin receptor autophosphorylation. CONCLUSION Treatment with rhIGF-I partially reversed severe progressive HOCM and renal tubular dysfunction in a patient with Donohue syndrome associated with a novel p.Leu795Pro INSR gene mutation causing a severe decrease in IR autophosphorylation.
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Affiliation(s)
- Tinka Hovnik
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, Bohoričeva 20, SI-1525, Ljubljana, Slovenia
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Kosova G, Urbanek M. Genetics of the polycystic ovary syndrome. Mol Cell Endocrinol 2013; 373:29-38. [PMID: 23079471 PMCID: PMC3609918 DOI: 10.1016/j.mce.2012.10.009] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 07/26/2012] [Accepted: 10/05/2012] [Indexed: 02/06/2023]
Abstract
Polycystic ovary syndrome (PCOS) is a highly complex endocrine disorder, characterized by hyperandrogenemia, menstrual irregularities and polycystic ovaries. A strong genetic component to the etiology of PCOS is evident. However, due to the genetic and phenotypic heterogeneity of PCOS and the lack of insufficiently large cohorts, studies to identify specific contributing genes to date have yielded only few conclusive results. In this review we discuss the current status of the genetic analysis of PCOS including the results of numerous association studies with candidate genes involved in TGF-β and insulin signaling, type 2 diabetes mellitus and obesity susceptibility. Furthermore, we address current challenges in genetic studies of PCOS, and the promise of new approaches, including genome-wide association studies and next-generation sequencing.
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Affiliation(s)
- Gülüm Kosova
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, United States
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40
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Valsamakis G, Lois K, Kumar S, Mastorakos G. Metabolic and other effects of pioglitazone as an add-on therapy to metformin in the treatment of polycystic ovary syndrome (PCOS). Hormones (Athens) 2013; 12:363-78. [PMID: 24121378 DOI: 10.1007/bf03401302] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Insulin resistance is a key pathogenic defect of the clustered metabolic disturbances seen in polycystic ovary syndrome (PCOS). Metformin is an insulin sensitizer acting in the liver and the peripheral tissues that ameliorates the metabolic and reproductive defects in PCOS. In addition, pioglitazone is an insulin sensitizer used in diabetes mellitus type 2 (T2DM), improving insulin resistance (IR) in adipose tissue and muscles. In T2DM, these drugs are also used as a combined treatment due to their "add-on effect" on insulin resistance. Although the beneficial role of troglitazone (a member of the thiazolidinediones (TZDs) family) in PCOS has been shown in the past, currently only pioglitazone is available in the market. A few small randomized controlled trials have directly compared the effectiveness of pioglitazone in women with PCOS, while there are a limited number of small studies that support the beneficial metabolic add-on effect of pioglitazone on metformin-treated PCOS women as compared to metformin or pioglitazone monotherapy. These findings suggest a potentially promising role for combined pioglitazone/metformin treatment in the management of PCOS in metformin-resistant patients. In view of recent concerns regarding pioglitazone usage and its associated health risk, we aim to compare the pros and cons of each drug regarding their metabolic and other hormonal effects in women with PCOS and to explore the possible beneficial effect of combined therapy in certain cases, taking into consideration the teratogenic effect of pioglitazone. Finally, we discuss the need for a randomized controlled trial that will evaluate the metabolic and other hormonal effects of combined metformin/pioglitazone treatment in PCOS with selective treatment targets.
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Affiliation(s)
- Georgios Valsamakis
- Warwickshire Institute for the Study of Diabetes, Endocrinology and Metabolism (WISDEM), University Hospitals Coventry and Warwickshire, Warwick Medical School, Coventry, UK, Endocrine Unit, Aretaieion University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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Diamanti-Kandarakis E, Dunaif A. Insulin resistance and the polycystic ovary syndrome revisited: an update on mechanisms and implications. Endocr Rev 2012; 33:981-1030. [PMID: 23065822 PMCID: PMC5393155 DOI: 10.1210/er.2011-1034] [Citation(s) in RCA: 1059] [Impact Index Per Article: 88.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Polycystic ovary syndrome (PCOS) is now recognized as an important metabolic as well as reproductive disorder conferring substantially increased risk for type 2 diabetes. Affected women have marked insulin resistance, independent of obesity. This article summarizes the state of the science since we last reviewed the field in the Endocrine Reviews in 1997. There is general agreement that obese women with PCOS are insulin resistant, but some groups of lean affected women may have normal insulin sensitivity. There is a post-binding defect in receptor signaling likely due to increased receptor and insulin receptor substrate-1 serine phosphorylation that selectively affects metabolic but not mitogenic pathways in classic insulin target tissues and in the ovary. Constitutive activation of serine kinases in the MAPK-ERK pathway may contribute to resistance to insulin's metabolic actions in skeletal muscle. Insulin functions as a co-gonadotropin through its cognate receptor to modulate ovarian steroidogenesis. Genetic disruption of insulin signaling in the brain has indicated that this pathway is important for ovulation and body weight regulation. These insights have been directly translated into a novel therapy for PCOS with insulin-sensitizing drugs. Furthermore, androgens contribute to insulin resistance in PCOS. PCOS may also have developmental origins due to androgen exposure at critical periods or to intrauterine growth restriction. PCOS is a complex genetic disease, and first-degree relatives have reproductive and metabolic phenotypes. Several PCOS genetic susceptibility loci have been mapped and replicated. Some of the same susceptibility genes contribute to disease risk in Chinese and European PCOS populations, suggesting that PCOS is an ancient trait.
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Nisticò R, Cavallucci V, Piccinin S, Macrì S, Pignatelli M, Mehdawy B, Blandini F, Laviola G, Lauro D, Mercuri NB, D'Amelio M. Insulin receptor β-subunit haploinsufficiency impairs hippocampal late-phase LTP and recognition memory. Neuromolecular Med 2012; 14:262-9. [PMID: 22661254 DOI: 10.1007/s12017-012-8184-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 04/24/2012] [Indexed: 11/24/2022]
Abstract
The insulin receptor (IR) is a protein tyrosine kinase playing a pivotal role in the regulation of peripheral glucose metabolism and energy homoeostasis. IRs are also abundantly distributed in the cerebral cortex and hippocampus, where they regulate synaptic activity required for learning and memory. As the major anabolic hormone in mammals, insulin stimulates protein synthesis partially through the activation of the PI3K/Akt/mTOR pathway, playing fundamental roles in neuronal development, synaptic plasticity and memory. Here, by means of a multidisciplinary approach, we report that long-term synaptic plasticity and recognition memory are impaired in IR β-subunit heterozygous mice. Since IR expression is diminished in type-2 diabetes as well as in Alzheimer's disease (AD) patients, these data may provide a mechanistic link between insulin resistance, impaired synaptic transmission and cognitive decline in humans with metabolic disorders.
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Affiliation(s)
- Robert Nisticò
- IRCCS Santa Lucia Foundation, Via del Fosso di Fiorano, 64/65, 00143, Rome, Italy.
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43
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Stears A, O'Rahilly S, Semple RK, Savage DB. Metabolic insights from extreme human insulin resistance phenotypes. Best Pract Res Clin Endocrinol Metab 2012; 26:145-57. [PMID: 22498245 DOI: 10.1016/j.beem.2011.09.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
As well as improving diagnostic and clinical outcomes for affected patients, understanding the genetic basis of rare human metabolic disorders has resulted in several fundamental biological insights. In some cases understanding extreme phenotypes has also informed thinking about more prevalent metabolic diseases. Insulin resistance underpins the twin epidemics of obesity and type 2 diabetes as well as accounting for many of the metabolic problems encompassed by the term metabolic syndrome. This review provides a brief update on current understanding of human severe insulin resistance syndromes, before highlighting recent insights provided by studies in these rare syndromes into the molecular pathogenesis of elements of the metabolic syndrome.
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Affiliation(s)
- Anna Stears
- Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Institute of Metabolic Science, University of Cambridge, UK
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44
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Alzahrani AS, Zou M, Baitei EY, Parhar RS, Al-Kahtani N, Raef H, Almahfouz A, Amartey JK, Al-Rijjal R, Hammami R, Meyer BF, Al-Mohanna FA, Shi Y. Molecular characterization of a novel p.R118C mutation in the insulin receptor gene from patients with severe insulin resistance. Clin Endocrinol (Oxf) 2012; 76:540-7. [PMID: 22017372 DOI: 10.1111/j.1365-2265.2011.04258.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
CONTEXT Mutations of the insulin receptor gene (INSR) can cause genetic syndromes associated with severe insulin resistance. OBJECTIVES We aimed to analyse INSR mutations in Saudi patients with severe insulin resistance. DESIGN Ten patients with Type A insulin resistance syndrome from five unrelated Saudi families were investigated. The entire coding region of INSR was sequenced. The founder effect was assessed by microsatellite haplotype analysis. The functional effect of the mutation was investigated by in vitro functional assays. RESULTS A novel biallelic c.433 C>T (p.R118C) mutation was detected in all patients. The c.433 C>T (p.R118C) sequence variation was not found in 100 population controls. The arginine residue at position 118 is located in the ligand-binding domain of INSR and is highly conserved across species. Microsatellite haplotype analysis of these patients indicated that p.R118C was a founder mutation created approximately 2900 years ago. The wild-type and mutant (R118C) INSR were cloned and expressed in CHO cells for functional analysis. Specific insulin binding to the mutant receptor was reduced by 83% as compared to wild-type (WT), although the mutant receptor was processed and expressed on the cell surface. Insulin-mediated receptor autophosphorylation was also significantly reduced in CHO(R118C) cells. CONCLUSIONS Biallelic c.433 C>T (p.R118C) mutation of INSR causes significant damage to insulin binding and insulin-mediated signal transduction. p.R118C is a founder mutation frequently present in the Saudi patients with severe insulin resistance.
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Affiliation(s)
- Ali S Alzahrani
- Department of Medicine, King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
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Marquez M, Huyvaert M, Perry JR, Pearson RD, Falchi M, Morris AP, Vivequin S, Lobbens S, Yengo L, Gaget S, Pattou F, Poulain-Godefroy O, Charpentier G, Carlsson LM, Jacobson P, Sjöström L, Lantieri O, Heude B, Walley A, Balkau B, Marre M, Froguel P, Cauchi S. Low-frequency variants in HMGA1 are not associated with type 2 diabetes risk. Diabetes 2012; 61:524-30. [PMID: 22210315 PMCID: PMC3266400 DOI: 10.2337/db11-0728] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 10/04/2011] [Indexed: 01/01/2023]
Abstract
It has recently been suggested that the low-frequency c.136-14_136-13insC variant in high-mobility group A1 (HMGA1) may strongly contribute to insulin resistance and type 2 diabetes risk. In our study, we attempted to confirm that HMGA1 is a novel type 2 diabetes locus in French Caucasians. The gene was sequenced in 368 type 2 diabetic case subjects with a family history of type 2 diabetes and 372 normoglycemic control subjects without a family history of type 2 diabetes. None of the 41 genetic variations identified were associated with type 2 diabetes. The lack of association between the c.136-14_136-13insC variant and type 2 diabetes was confirmed in an independent French group of 4,538 case subjects and 4,015 control subjects and in a large meta-analysis of 16,605 case subjects and 46,179 control subjects. Finally, this variant had no effects on metabolic traits and was not involved in variations of HMGA1 and insulin receptor (INSR) expressions. The c.136-14_136-13insC variant was not associated with type 2 diabetes in individuals of European descent. Our study emphasizes the need to analyze a large number of subjects to reliably assess the association of low-frequency variants with the disease.
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Affiliation(s)
- Marcel Marquez
- UMR CNRS 8199, Genomic and Metabolic Disease, Lille, France
| | | | - John R.B. Perry
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, U.K
- Genetics of Complex Traits, Peninsula Medical School, University of Exeter, Exeter, U.K
| | - Richard D. Pearson
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, U.K
| | - Mario Falchi
- Genomic Medicine, Hammersmith Hospital, Imperial College London, London, U.K
| | - Andrew P. Morris
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, U.K
| | | | | | - Loïc Yengo
- UMR CNRS 8199, Genomic and Metabolic Disease, Lille, France
| | - Stefan Gaget
- UMR CNRS 8199, Genomic and Metabolic Disease, Lille, France
| | | | | | - Guillaume Charpentier
- Corbeil-Essonnes Hospital, Department of Endocrinology-Diabetology, Corbeil-Essonnes, France
| | - Lena M.S. Carlsson
- Department of Molecular and Clinical Medicine and Center for Cardiovascular and Metabolic Research, The Sahlgrenska Academy, Gothenburg, Sweden
| | - Peter Jacobson
- Department of Molecular and Clinical Medicine and Center for Cardiovascular and Metabolic Research, The Sahlgrenska Academy, Gothenburg, Sweden
| | - Lars Sjöström
- Department of Molecular and Clinical Medicine and Center for Cardiovascular and Metabolic Research, The Sahlgrenska Academy, Gothenburg, Sweden
| | | | - Barbara Heude
- INSERM Centre de recherche en Epidémiologie et Santé des Populations U1018, Villejuif, France
| | - Andrew Walley
- Genomic Medicine, Hammersmith Hospital, Imperial College London, London, U.K
| | - Beverley Balkau
- INSERM Centre de recherche en Epidémiologie et Santé des Populations U1018, Villejuif, France
| | - Michel Marre
- Endocrinology-Diabetology-Nutrition, Bichat-Claude Bernard Hospital, Paris, France, and the University Denis Diderot Paris 7, Paris, France
| | | | - Philippe Froguel
- UMR CNRS 8199, Genomic and Metabolic Disease, Lille, France
- Genomic Medicine, Hammersmith Hospital, Imperial College London, London, U.K
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Abstract
Sir Harold Himsworth first observed and articulated the phenomenon of insulin resistance in the late 1930s. Although a long delay followed before his observations were acknowledged and enshrined in formal diagnostic classifications of diabetes mellitus, insulin resistance-related pathology in the early 21st century poses one of the major global healthcare challenges for contemporary physicians. Whilst insulin resistance is closely related to obesity and decreased physical fitness, despite intensive investigation it has proved extremely challenging to discriminate key events in its causation from epiphenomena, many related to compensation for the primary defect. Thus, a complete account of the molecular pathogenesis of insulin resistance-related diseases remains elusive. One approach circumventing such problems is the study of patients with single gene defects causing severe insulin resistance. In such patients the primary defect is known, and thus lessons may be learned about human physiology from detailed physiological study allied to knowledge of the function of the mutated protein. This review discusses developments in understanding of monogenic severe insulin resistance since discovery of the first insulin receptor mutations in 1988 and reviews the physiological lessons learnt, including the critical role of adipose tissue in human metabolic health and the meaning and importance of 'partial' insulin resistance for major human disease.
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Affiliation(s)
- V E R Parker
- University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
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47
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Geller DH, Pacaud D, Gordon CM, Misra M. State of the Art Review: Emerging Therapies: The Use of Insulin Sensitizers in the Treatment of Adolescents with Polycystic Ovary Syndrome (PCOS). INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2011; 2011:9. [PMID: 21899727 PMCID: PMC3180691 DOI: 10.1186/1687-9856-2011-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 08/26/2011] [Indexed: 12/14/2022]
Abstract
PCOS, a heterogeneous disorder characterized by cystic ovarian morphology, androgen excess, and/or irregular periods, emerges during or shortly after puberty. Peri- and post-pubertal obesity, insulin resistance and consequent hyperinsulinemia are highly prevalent co-morbidities of PCOS and promote an ongoing state of excess androgen. Given the relationship of insulin to androgen excess, reduction of insulin secretion and/or improvement of its action at target tissues offer the possibility of improving the physical stigmata of androgen excess by correction of the reproductive dysfunction and preventing metabolic derangements from becoming entrenched. While lifestyle changes that concentrate on behavioral, dietary and exercise regimens should be considered as first line therapy for weight reduction and normalization of insulin levels in adolescents with PCOS, several therapeutic options are available and in wide use, including oral contraceptives, metformin, thiazolidenediones and spironolactone. Overwhelmingly, the data on the safety and efficacy of these medications derive from the adult PCOS literature. Despite the paucity of randomized control trials to adequately evaluate these modalities in adolescents, their use, particularly that of metformin, has gained popularity in the pediatric endocrine community. In this article, we present an overview of the use of insulin sensitizing medications in PCOS and review both the adult and (where available) adolescent literature, focusing specifically on the use of metformin in both mono- and combination therapy.
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Affiliation(s)
- David H Geller
- Division of Pediatric Endocrinology, Cedars-Sinai Medical Center, David Geffen-UCLA School of Medicine 8700 Beverly Blvd,, Rm 4220, Los Angeles, CA 90048, USA.
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48
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Shimizu T, Baba T, Ogawara M, Shirasawa T. Lifespan and glucose metabolism in insulin receptor mutant mice. J Aging Res 2011; 2011:315640. [PMID: 21876806 PMCID: PMC3159008 DOI: 10.4061/2011/315640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2011] [Revised: 04/15/2011] [Accepted: 05/19/2011] [Indexed: 11/30/2022] Open
Abstract
Insulin/insulin-like growth factor type 1 signaling regulates lifespan and resistance to oxidative stress in worms, flies, and mammals. In a previous study, we revealed that insulin receptor (IR) mutant mice, which carry a homologous mutation found in the long-lived daf-2 mutant of Caenorhabditis elegans, showed enhanced resistance to oxidative stress cooperatively modulated by sex hormones and dietary signals (Baba et al., (2005)). We herein investigated the lifespan of IR mutant mice to evaluate the biological significance of insulin signaling in mice. Under normoxia, mutant male mice had a lifespan comparable to that of wild-type male mice. IR mutant female mice also showed a lifespan similar to that of wild-type female mice, in spite of the fact that the IR mutant female mice acquired more resistance to oxidative stress than IR mutant male mice. On the other hand, IR mutant male and female mice both showed insulin resistance with hyperinsulinemia, but they did not develop hyperglycemia throughout their entire lifespan. These data indicate that the IR mutation does not impact the lifespan in mice, thus suggesting that insulin signaling might have a limited effect on the lifespan of mice.
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Affiliation(s)
- Takahiko Shimizu
- Molecular Gerontology, Tokyo Metropolitan Institute of Gerontology, 35-2 Sakae-cho, Itabashi-ku, Tokyo 173-0015, Japan
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Kirilmaz B, Asgun F, Alioglu E, Ercan E, Tengiz I, Turk U, Saygi S, Ozerkan F. High inflammatory activity related to the number of metabolic syndrome components. J Clin Hypertens (Greenwich) 2011; 12:136-44. [PMID: 20167041 DOI: 10.1111/j.1751-7176.2009.00229.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
It has been known that each component of the metabolic syndrome (MS) has an atherogenic potential and increases the risk of cardiovascular events. Therefore, patients who have MS are candidates for the development of atherosclerosis and accompanying complications. In this study, the authors assessed the levels of acute phase reactants as an indicator of inflammation in patients with MS. Twenty-five patients with recently diagnosed MS and not treated before who had at least 3 of 5 diagnostic criteria of MS listed in the Third Report of the Adult Treatment Panel National Cholesterol Education Program (NCEP-ATP III) guidelines were included in the study. Twenty healthy patients constituted the control group. Inflammatory parameters were compared between the groups. There was no significant difference between the MS and control group with regard to age and sex. White blood cell count (/mm(3)), high-sensitivity C-reactive protein (hs-CRP), uric acid, interleukin (IL) 6, and fibrinogen levels were found to be significantly higher in the MS group. Number of MS components was strongly correlated with serum levels of hs-CRP (r=0.688, P=.0001), IL-6 (r=0.546, P=.0001), fibrinogen (r=0.551, P=.0001), uric acid (r=0.517, P=.0001), and leucocyte count (/mm(3)) (r=0.456, P=.002). Inflammation plays an important role in atherosclerotic complications, which is activated in MS. Increased number of MS components are strongly associated with elevated inflammatory and metabolic markers. Measurement of serum inflammatory parameters in patients with MS may be beneficial in detection and management of cardiovascular events and in the assessment of efficacy of treatment.
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Affiliation(s)
- Bahadir Kirilmaz
- Department of Cardiology, Canakkale Onsekiz Mart University Faculty of Medicine, Canakkale, Turkey.
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Raffan E, Soos MA, Rocha N, Tuthill A, Thomsen AR, Hyden CS, Gregory JW, Hindmarsh P, Dattani M, Cochran E, Al Kaabi J, Gorden P, Barroso I, Morling N, O’Rahilly S, Semple RK. Founder effect in the Horn of Africa for an insulin receptor mutation that may impair receptor recycling. Diabetologia 2011; 54:1057-65. [PMID: 21318406 PMCID: PMC3071941 DOI: 10.1007/s00125-011-2066-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2010] [Accepted: 01/07/2011] [Indexed: 11/26/2022]
Abstract
AIMS/HYPOTHESIS Genetic insulin receptoropathies are a rare cause of severe insulin resistance. We identified the Ile119Met missense mutation in the insulin receptor INSR gene, previously reported in a Yemeni kindred, in four unrelated patients with Somali ancestry. We aimed to investigate a possible genetic founder effect, and to study the mechanism of loss of function of the mutant receptor. METHODS Biochemical profiling and DNA haplotype analysis of affected patients were performed. Insulin receptor expression in lymphoblastoid cells from a homozygous p.Ile119Met INSR patient, and in cells heterologously expressing the mutant receptor, was examined. Insulin binding, insulin-stimulated receptor autophosphorylation, and cooperativity and pH dependency of insulin dissociation were also assessed. RESULTS All patients had biochemical profiles pathognomonic of insulin receptoropathy, while haplotype analysis revealed the putative shared region around the INSR mutant to be no larger than 28 kb. An increased insulin proreceptor to β subunit ratio was seen in patient-derived cells. Steady state insulin binding and insulin-stimulated autophosphorylation of the mutant receptor was normal; however it exhibited decreased insulin dissociation rates with preserved cooperativity, a difference accentuated at low pH. CONCLUSIONS/INTERPRETATION The p.Ile119Met INSR appears to have arisen around the Horn of Africa, and should be sought first in severely insulin resistant patients with ancestry from this region. Despite collectively compelling genetic, clinical and biochemical evidence for its pathogenicity, loss of function in conventional in vitro assays is subtle, suggesting mildly impaired receptor recycling only.
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Affiliation(s)
- E. Raffan
- University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital B289, Cambridge, CB2 0QR UK
| | - M. A. Soos
- University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital B289, Cambridge, CB2 0QR UK
| | - N. Rocha
- University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital B289, Cambridge, CB2 0QR UK
| | - A. Tuthill
- University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital B289, Cambridge, CB2 0QR UK
| | - A. R. Thomsen
- Section of Forensic Genetics, Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - C. S. Hyden
- University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital B289, Cambridge, CB2 0QR UK
| | - J. W. Gregory
- Department of Child Health, Wales School of Medicine, Cardiff University, Cardiff, UK
| | - P. Hindmarsh
- Institute of Child Health, University College London, London, UK
| | - M. Dattani
- Institute of Child Health, University College London, London, UK
| | - E. Cochran
- Clinical Endocrinology Branch, National Institute of Diabetes, Digestive and Kidney Diseases, Bethesda, MD USA
| | - J. Al Kaabi
- Faculty of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - P. Gorden
- Clinical Endocrinology Branch, National Institute of Diabetes, Digestive and Kidney Diseases, Bethesda, MD USA
| | - I. Barroso
- University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital B289, Cambridge, CB2 0QR UK
- The Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Cambridge, UK
| | - N. Morling
- Section of Forensic Genetics, Department of Forensic Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S. O’Rahilly
- University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital B289, Cambridge, CB2 0QR UK
| | - R. K. Semple
- University of Cambridge Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke’s Hospital B289, Cambridge, CB2 0QR UK
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