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Zhang H, Colclough K, Gloyn AL, Pollin TI. Monogenic diabetes: a gateway to precision medicine in diabetes. J Clin Invest 2021; 131:142244. [PMID: 33529164 PMCID: PMC7843214 DOI: 10.1172/jci142244] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Monogenic diabetes refers to diabetes mellitus (DM) caused by a mutation in a single gene and accounts for approximately 1%-5% of diabetes. Correct diagnosis is clinically critical for certain types of monogenic diabetes, since the appropriate treatment is determined by the etiology of the disease (e.g., oral sulfonylurea treatment of HNF1A/HNF4A-diabetes vs. insulin injections in type 1 diabetes). However, achieving a correct diagnosis requires genetic testing, and the overlapping of the clinical features of monogenic diabetes with those of type 1 and type 2 diabetes has frequently led to misdiagnosis. Improvements in sequencing technology are increasing opportunities to diagnose monogenic diabetes, but challenges remain. In this Review, we describe the types of monogenic diabetes, including common and uncommon types of maturity-onset diabetes of the young, multiple causes of neonatal DM, and syndromic diabetes such as Wolfram syndrome and lipodystrophy. We also review methods of prioritizing patients undergoing genetic testing, and highlight existing challenges facing sequence data interpretation that can be addressed by forming collaborations of expertise and by pooling cases.
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Affiliation(s)
- Haichen Zhang
- University of Maryland School of Medicine, Department of Medicine, Baltimore, Maryland, USA
| | - Kevin Colclough
- Exeter Genomics Laboratory, Royal Devon and Exeter Hospital, Exeter, United Kingdom
| | - Anna L. Gloyn
- Department of Pediatrics, Division of Endocrinology, and,Stanford Diabetes Research Center, Stanford School of Medicine, Stanford, California, USA
| | - Toni I. Pollin
- University of Maryland School of Medicine, Department of Medicine, Baltimore, Maryland, USA
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Hulín J, Škopková M, Valkovičová T, Mikulajová S, Rosoľanková M, Papcun P, Gašperíková D, Staník J. Clinical implications of the glucokinase impaired function - GCK MODY today. Physiol Res 2020; 69:995-1011. [PMID: 33129248 DOI: 10.33549/physiolres.934487] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Heterozygous inactivating mutations of the glucokinase (GCK) gene are causing GCK-MODY, one of the most common forms of the Maturity Onset Diabetes of the Young (MODY). GCK-MODY is characterized by fasting hyperglycemia without apparent worsening with aging and low risk for chronic vascular complications. Despite the mild clinical course, GCK-MODY could be misdiagnosed as type 1 or type 2 diabetes. In the diagnostic process, the clinical suspicion is often based on the clinical diagnostic criteria for GCK-MODY and should be confirmed by DNA analysis. However, there are several issues in the clinical and also in genetic part that could complicate the diagnostic process. Most of the people with GCK-MODY do not require any pharmacotherapy. The exception are pregnant women with a fetus which did not inherit GCK mutation from the mother. Such a child has accelerated growth, and has increased risk for diabetic foetopathy. In this situation the mother should be treated with substitutional doses of insulin. Therefore, distinguishing GCK-MODY from gestational diabetes in pregnancy is very important. For this purpose, special clinical diagnostic criteria for clinical identification of GCK-MODY in pregnancy are used. This review updates information on GCK-MODY and discusses several currently not solved problems in the clinical diagnostic process, genetics, and treatment of this type of monogenic diabetes.
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Affiliation(s)
- J Hulín
- Department of Pediatrics, Medical Faculty of the Comenius University, Bratislava, Slovakia.
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Hohendorff J, Zapala B, Ludwig-Slomczynska AH, Solecka I, Ucieklak D, Matejko B, Mrozinska S, Malecki MT, Szopa M. The utility of MODY Probability Calculator in probands of families with early-onset autosomal dominant diabetes from Poland. Minerva Med 2020; 110:499-506. [DOI: 10.23736/s0026-4806.19.06053-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Peixoto-Barbosa R, Reis AF, Giuffrida FMA. Update on clinical screening of maturity-onset diabetes of the young (MODY). Diabetol Metab Syndr 2020; 12:50. [PMID: 32528556 PMCID: PMC7282127 DOI: 10.1186/s13098-020-00557-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/29/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Maturity-onset diabetes of the young (MODY) is the most common type of monogenic diabetes, being characterized by beta-cell disfunction, early onset, and autosomal dominant inheritance. Despite the rapid evolution of molecular diagnosis methods, many MODY cases are misdiagnosed as type 1 or type 2 diabetes. High costs of genetic testing and limited knowledge of MODY as a relevant clinical entity are some of the obstacles that hinder correct MODY diagnosis and treatment. We present a broad review of clinical syndromes related to most common MODY subtypes, emphasizing the role of biomarkers that can help improving the accuracy of clinical selection of candidates for molecular diagnosis. MAIN BODY To date, MODY-related mutations have been reported in at least 14 different genes. Mutations in glucokinase (GCK), hepatocyte nuclear factor-1 homeobox A (HNF1A), and hepatocyte nuclear factor-4 homeobox A (HNF4A) are the most common causes of MODY. Accurate etiological diagnosis can be challenging. Many biomarkers such as apolipoprotein-M (ApoM), aminoaciduria, complement components, and glycosuria have been tested, but have not translated into helpful diagnostic tools. High-sensitivity C-reactive protein (hs-CRP) levels are lower in HNF1A-MODY and have been tested in some studies to discriminate HNF1A-MODY from other types of diabetes, although more data are needed. Overall, presence of pancreatic residual function and absence of islet autoimmunity seem the most promising clinical instruments to select patients for further investigation. CONCLUSIONS The selection of diabetic patients for genetic testing is an ongoing challenge. Metabolic profiling, diabetes onset age, pancreatic antibodies, and C-peptide seem to be useful tools to better select patients for genetic testing. Further studies are needed to define cut-off values in different populations.
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Affiliation(s)
- Renata Peixoto-Barbosa
- Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo (UNIFESP), Rua Estado de Israel, 639–Vila Clementino, São Paulo, SP CEP: 04022-001 Brazil
- Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB), Salvador, Brazil
| | - André F. Reis
- Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo (UNIFESP), Rua Estado de Israel, 639–Vila Clementino, São Paulo, SP CEP: 04022-001 Brazil
| | - Fernando M. A. Giuffrida
- Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo (UNIFESP), Rua Estado de Israel, 639–Vila Clementino, São Paulo, SP CEP: 04022-001 Brazil
- Departamento de Ciências da Vida, Universidade do Estado da Bahia (UNEB), Salvador, Brazil
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Desai P, Donovan L, Janowitz E, Kim JY. The Clinical Utility of Salivary Biomarkers in the Identification of Type 2 Diabetes Risk and Metabolic Syndrome. Diabetes Metab Syndr Obes 2020; 13:3587-3599. [PMID: 33116710 PMCID: PMC7553598 DOI: 10.2147/dmso.s265879] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/04/2020] [Indexed: 12/12/2022] Open
Abstract
Type 2 diabetes is traditionally diagnosed by the use of an oral glucose tolerance test and/or HbA1c, both of which require serum collection. Various biomarkers, which are measurable biological substances that provide clinical insight on disease state, have also been effective in the early identification and risk prediction of inflammatory diseases. Measuring biomarker concentrations has traditionally been obtained through serum collection as well. However, numerous biomarkers are detectable in saliva. Salivary analysis has more recently been introduced into research as a potential non-invasive, cost-effective diagnostic for the early identification of type 2 diabetes risk in adults and youth. Therefore, the purpose of this review was to compare 6 established inflammatory biomarkers of type 2 diabetes, in serum and saliva, and determine if similar diagnostic effectiveness is seen in saliva. A lack of standardized salivary analysis, processing, and collection accounts for errors and inconsistencies in conclusive data amongst studies. Proposing a national standardization in salivary analysis, coupled with increased data and research on the utility of saliva as a diagnostic, poses the potential for salivary analysis to be used in diagnostic settings.
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Affiliation(s)
- Priya Desai
- Department of Exercise Science, Syracuse University, Syracuse, NY, USA
| | - Lorin Donovan
- Department of Exercise Science, Syracuse University, Syracuse, NY, USA
| | | | - Joon Young Kim
- Department of Exercise Science, Syracuse University, Syracuse, NY, USA
- Correspondence: Joon Young KimDepartment of Exercise Science, Syracuse University, Women’s Building 204E, 820 Comstock Ave, Syracuse, NY13244, USATel +1 315-443-1411Fax +1 315-443-9375 Email
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Szopa M, Klupa T, Kapusta M, Matejko B, Ucieklak D, Glodzik W, Zapala B, Sani CM, Hohendorff J, Malecki MT, Skupien J. A decision algorithm to identify patients with high probability of monogenic diabetes due to HNF1A mutations. Endocrine 2019; 64:75-81. [PMID: 30778899 PMCID: PMC6453873 DOI: 10.1007/s12020-019-01863-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/05/2019] [Indexed: 11/09/2022]
Abstract
PURPOSE To investigate the utility of biomarkers of maturity-onset diabetes of the young (MODY), high-sensitivity C-reactive protein (hsCRP), and 1,5-anhydroglucitol (1,5-AG) in conjunction with other clinical and laboratory features to improve diagnostic accuracy and provide a diagnostic algorithm for HNF1A MODY. METHODS We examined 77 patients with HNF1A MODY, 88 with GCK MODY mutations, 99 with type 1 diabetes, and 92 with type 2 diabetes. In addition to 1,5-AG and hsCRP, we considered body mass index (BMI), fasting glucose, and fasting serum C-peptide as potential biomarkers. Logistic regression and receiver operating characteristic curves were used in marker evaluation. RESULTS Concentration of hsCRP was lowest in HNF1A MODY (0.51 mg/l) and highest in type 2 diabetes (1.33 mg/l). The level of 1,5-AG was lowest in type 1 diabetes and HNF1A MODY, 3.8 and 4.7 μg/ml, respectively, and highest (11.2 μg/ml) in GCK MODY. In the diagnostic algorithm, we first excluded patients with type 1 diabetes based on low C-peptide (C-statistic 0.98) before using high BMI and C-peptide to identify type 2 diabetes patients (C-statistic 0.92). Finally, 1,5-AG and hsCRP in conjunction yielded a C-statistic of 0.86 in discriminating HNF1A from GCK MODY. We correctly classified 92.9% of patients with type 1 diabetes, 84.8% with type 2 diabetes, 64.9% HNF1A MODY, and 52.3% GCK MODY patients. CONCLUSIONS Plasma 1,5-AG and serum hsCRP do not discriminate sufficiently HNF1A MODY from common diabetes types, but could be potentially useful in prioritizing Sanger sequencing of HNF1A gene.
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Affiliation(s)
- Magdalena Szopa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Klupa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Maria Kapusta
- Department of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - Bartlomiej Matejko
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Damian Ucieklak
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | | | - Barbara Zapala
- Department of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - Cyrus Maurice Sani
- School of Medicine in English, Jagiellonian University Medical College, Krakow, Poland
| | - Jerzy Hohendorff
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej T Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
| | - Jan Skupien
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland.
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Zheng Y, Shen Y, Jiang S, Ma X, Hu J, Li C, Huang Y, Teng Y, Bao Y, Zhou J, Hu G, Tao M. Maternal glycemic parameters and adverse pregnancy outcomes among high-risk pregnant women. BMJ Open Diabetes Res Care 2019; 7:e000774. [PMID: 31798901 PMCID: PMC6861069 DOI: 10.1136/bmjdrc-2019-000774] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/10/2019] [Accepted: 10/16/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE We aimed to investigate the association between maternal glycemic parameters and adverse pregnancy outcomes among high-risk pregnant women. RESEARCH DESIGN AND METHODS A total of 1976 high-risk pregnant women were enrolled between 2015 and 2017. All participants received a 75 g oral glucose tolerance test during the 24-30 gestational weeks and complete birth and delivery information was collected. Adverse pregnancy outcomes were defined as premature birth, birth weight >90th percentile, primary cesarean section, and pre-eclampsia. Logistic regression models were used to assess the association between five maternal glycemic parameters during pregnancy (fasting glucose, 1-hour glucose, 2-hour glucose, HbA1c, and serum 1,5-anhydroglucitol (1,5-AG)) and adverse pregnancy outcomes. RESULTS Of 1976 participants, 498 were diagnosed with gestational diabetes. The multivariable-adjusted ORs of adverse pregnancy outcomes for each one unit increase (1 mmol/L, 1%, or 1 µg/mL) were 2.32 (95% CI 1.85 to 2.92) for fasting glucose, 1.07 (95% CI 1.01 to 1.15) for 1-hour glucose, 1.03 (95% CI 0.96 to 1.10) for 2-hour glucose, 1.77 (95% CI 1.34 to 2.33) for HbA1c, and 0.96 (95% CI 0.94 to 0.98) for 1,5-AG, respectively. When all five glycemic parameters were simultaneously entered into the multivariable-adjusted model, only fasting glucose was significantly associated with total and individual adverse pregnancy outcomes. Receiver operating characteristic curve showed that fasting glucose plus any one of other four glycemic parameters had significantly enhanced the sensitivity of detecting adverse pregnancy outcomes. CONCLUSIONS Fasting glucose at 24-30 gestational weeks was strongly associated with adverse pregnancy outcomes. Fasting glucose combined with one additional glycemic measurement showed non-inferiority indicating that post-load glycemic measurement was not necessary in detecting adverse pregnancy outcomes among high-risk pregnant women.
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Affiliation(s)
- Yanwei Zheng
- Department of Obstetric and Gynaecology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yun Shen
- Chronic Disease Epidemiology, Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Susu Jiang
- Department of Obstetric and Gynaecology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Xiaojing Ma
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jiangshan Hu
- Department of Obstetric and Gynaecology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Changbin Li
- Department of Obstetric and Gynaecology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yajuan Huang
- Department of Obstetric and Gynaecology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yincheng Teng
- Department of Obstetric and Gynaecology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yuqian Bao
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jian Zhou
- Chronic Disease Epidemiology, Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
- Department of Endocrinology and Metabolism, Shanghai Clinical Center for Diabetes, Shanghai Diabetes Institute, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Gang Hu
- Chronic Disease Epidemiology, Pennington Biomedical Research Center, Baton Rouge, Louisiana, USA
| | - Minfang Tao
- Department of Obstetric and Gynaecology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
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Hohendorff J, Szopa M, Skupien J, Kapusta M, Zapala B, Platek T, Mrozinska S, Parpan T, Glodzik W, Ludwig-Galezowska A, Kiec-Wilk B, Klupa T, Malecki MT. A single dose of dapagliflozin, an SGLT-2 inhibitor, induces higher glycosuria in GCK- and HNF1A-MODY than in type 2 diabetes mellitus. Endocrine 2017; 57:272-279. [PMID: 28593615 PMCID: PMC5511327 DOI: 10.1007/s12020-017-1341-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 06/01/2017] [Indexed: 02/06/2023]
Abstract
AIMS SGLT2 inhibitors are a new class of oral hypoglycemic agents used in type 2 diabetes (T2DM). Their effectiveness in maturity onset diabetes of the young (MODY) is unknown. We aimed to assess the response to a single dose of 10 mg dapagliflozin in patients with Hepatocyte Nuclear Factor 1 Alpha (HNF1A)-MODY, Glucokinase (GCK)-MODY, and type 2 diabetes. METHODS We examined 14 HNF1A-MODY, 19 GCK-MODY, and 12 type 2 diabetes patients. All studied individuals received a single morning dose of 10 mg of dapagliflozin added to their current therapy of diabetes. To assess the response to dapagliflozin we analyzed change in urinary glucose to creatinine ratio and serum 1,5-Anhydroglucitol (1,5-AG) level. RESULTS There were only four patients with positive urine glucose before dapagliflozin administration (one with HNF1A-MODY, two with GCK-MODY, and one with T2DM), whereas after SGLT-2 inhibitor use, glycosuria occurred in all studied participants. Considerable changes in mean glucose to creatinine ratio after dapagliflozin administration were observed in all three groups (20.51 ± 12.08, 23.19 ± 8.10, and 9.84 ± 6.68 mmol/mmol for HNF1A-MODY, GCK-MODY, and T2DM, respectively, p < 0.001 for all comparisons). Post-hoc analysis revealed significant differences in mean glucose to creatinine ratio change between type 2 diabetes and each monogenic diabetes in response to dapagliflozin (p = 0.02, p = 0.003 for HNF1-A and GCK MODY, respectively), but not between the two MODY forms (p = 0.7231). Significant change in serum 1,5-AG was noticed only in T2DM and it was -6.57 ± 7.34 mg/ml (p = 0.04). CONCLUSIONS A single dose of dapagliflozin, an SGLT-2 inhibitor, induces higher glycosuria in GCK- and HNF1A-MODY than in T2DM. Whether flozins are a valid therapeutic option in these forms of MODY requires long-term clinical studies.
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Affiliation(s)
- J Hohendorff
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - M Szopa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - J Skupien
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - M Kapusta
- Department of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - B Zapala
- Department of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - T Platek
- Department of Clinical Biochemistry, Jagiellonian University Medical College, Krakow, Poland
| | - S Mrozinska
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - T Parpan
- Brothers Hospitallers' of St. John of God Hospital, Krakow, Poland
| | - W Glodzik
- Sanatio Medical Center, Krakow, Poland
| | - A Ludwig-Galezowska
- Center for Medical Genomics OMICRON, Jagiellonian University Medical College, Krakow, Poland
| | - B Kiec-Wilk
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - T Klupa
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland
- Department of Metabolic Diseases, University Hospital, Krakow, Poland
| | - M T Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, Krakow, Poland.
- Department of Metabolic Diseases, University Hospital, Krakow, Poland.
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Wright LAC, Hirsch IB. Metrics Beyond Hemoglobin A1C in Diabetes Management: Time in Range, Hypoglycemia, and Other Parameters. Diabetes Technol Ther 2017; 19:S16-S26. [PMID: 28541136 PMCID: PMC5444503 DOI: 10.1089/dia.2017.0029] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We review clinical instances in which A1C should not be used and reflect on the use of other glucose metrics that can be used, in substitution of or in combination with A1C and SMBG, to tailor an individualized approach that will result in better outcomes and patient empowerment.
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Affiliation(s)
- Lorena Alarcon-Casas Wright
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington Medical Center/Roosevelt , Seattle, Washington
| | - Irl B Hirsch
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington Medical Center/Roosevelt , Seattle, Washington
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Althari S, Gloyn AL. When is it MODY? Challenges in the Interpretation of Sequence Variants in MODY Genes. Rev Diabet Stud 2016; 12:330-48. [PMID: 27111119 DOI: 10.1900/rds.2015.12.330] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
The genomics revolution has raised more questions than it has provided answers. Big data from large population-scale resequencing studies are increasingly deconstructing classic notions of Mendelian disease genetics, which support a simplistic correlation between mutational severity and phenotypic outcome. The boundaries are being blurred as the body of evidence showing monogenic disease-causing alleles in healthy genomes, and in the genomes of individu-als with increased common complex disease risk, continues to grow. In this review, we focus on the newly emerging challenges which pertain to the interpretation of sequence variants in genes implicated in the pathogenesis of maturity-onset diabetes of the young (MODY), a presumed mono-genic form of diabetes characterized by Mendelian inheritance. These challenges highlight the complexities surrounding the assignments of pathogenicity, in particular to rare protein-alerting variants, and bring to the forefront some profound clinical diagnostic implications. As MODY is both genetically and clinically heterogeneous, an accurate molecular diagnosis and cautious extrapolation of sequence data are critical to effective disease management and treatment. The biological and translational value of sequence information can only be attained by adopting a multitude of confirmatory analyses, which interrogate variant implication in disease from every possible angle. Indeed, studies which have effectively detected rare damaging variants in known MODY genes in normoglycemic individuals question the existence of a sin-gle gene mutation scenario: does monogenic diabetes exist when the genetic culprits of MODY have been systematical-ly identified in individuals without MODY?
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Affiliation(s)
- Sara Althari
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, UK
| | - Anna L Gloyn
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, UK
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den Ouden H, Pellis L, Rutten GEHM, Geerars-van Vonderen IK, Rubingh CM, van Ommen B, van Erk MJ, Beulens JWJ. Metabolomic biomarkers for personalised glucose lowering drugs treatment in type 2 diabetes. Metabolomics 2016; 12:27. [PMID: 26770180 PMCID: PMC4703625 DOI: 10.1007/s11306-015-0930-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/17/2015] [Indexed: 02/06/2023]
Abstract
We aimed to identify metabolites to predict patients' response to glucose lowering treatment during the first 5 years after detection of type 2 diabetes. Metabolites were measured by GC-MS in baseline samples from 346 screen-detected type 2 diabetes patients in the ADDITION-NL study. The response to treatment with metformin and/or sulphonylurea (SU) was analysed to identify metabolites predictive of 5 year HbA1c change by multiple regression analysis. Baseline glucose and 1,5 anhydro-glucitol were associated with HbA1c decrease in all medication groups. In patients on SU no other metabolite was associated with HbA1c decrease. A larger set of metabolites was associated with HbA1c change in the metformin and the combination therapy (metformin + SU) groups. These metabolites included metabolites related to liver metabolism, such as 2-hydroxybutanoic acid, 3-hydroxybutanoic acid, 2-hydroxypiperidine and 4-oxoproline). Metabolites involved in oxidative stress and insulin resistance were higher when the HbA1c decrease was larger in the metformin/sulphonylurea group. The associations between baseline metabolites and responsiveness to medication are in line with its mode of action. If these results could be replicated in other populations, the most promising predictive candidates might be tested to assess whether they could enhance personalised treatment.
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Affiliation(s)
- Henk den Ouden
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Str. 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - Linette Pellis
- TNO, Microbiology and Systems Biology Group, Utrechtseweg 48, 3704 HE Zeist, The Netherlands
| | - Guy E. H. M. Rutten
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Str. 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | | | - Carina M. Rubingh
- TNO, Microbiology and Systems Biology Group, Utrechtseweg 48, 3704 HE Zeist, The Netherlands
| | - Ben van Ommen
- TNO, Microbiology and Systems Biology Group, Utrechtseweg 48, 3704 HE Zeist, The Netherlands
| | - Marjan J. van Erk
- TNO, Microbiology and Systems Biology Group, Utrechtseweg 48, 3704 HE Zeist, The Netherlands
| | - Joline W. J. Beulens
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Str. 6.131, PO Box 85500, 3508 GA Utrecht, The Netherlands
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Ciucanu I, Pilat L, Ciucanu CI, Şişu E. Determination of Neutral Monosaccharides as Per-O-methylated Derivatives Directly from a Drop of Whole Blood by Gas Chromatography–Mass Spectrometry. Anal Chem 2015; 87:10856-61. [DOI: 10.1021/acs.analchem.5b02252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Ionel Ciucanu
- Department
of Chemistry, West University of Timisoara, Strada Pestalozzi 16, RO-300115 Timisoara, Romania
| | - Luminiţa Pilat
- Department
of Chemistry, West University of Timisoara, Strada Pestalozzi 16, RO-300115 Timisoara, Romania
| | - Cristian Ionuţ Ciucanu
- Faculty
of Medicine, “Victor Babes” University of Medicine and Pharmacy of Timisoara, Piaţa Eftimie Murgu 2, RO-300041 Timisoara, Romania
| | - Eugen Şişu
- Faculty
of Medicine, “Victor Babes” University of Medicine and Pharmacy of Timisoara, Piaţa Eftimie Murgu 2, RO-300041 Timisoara, Romania
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13
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Kim MJ, Jung HS, Hwang-Bo Y, Cho SW, Jang HC, Kim SY, Park KS. Evaluation of 1,5-anhydroglucitol as a marker for glycemic variability in patients with type 2 diabetes mellitus. Acta Diabetol 2013; 50:505-10. [PMID: 21688018 DOI: 10.1007/s00592-011-0302-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 06/02/2011] [Indexed: 11/30/2022]
Abstract
1,5-anhydroglucitol (1,5-AG) has been suggested as a marker for short-term glycemic control and postprandial hyperglycemia. However, the role of 1,5-AG in glycemic variability has not been established. The aim of this study was to demonstrate the usefulness of 1,5-AG as a marker for glycemic variability in patients with type 2 diabetes. Sixty patients with type 2 diabetes were enrolled, and a continuous glucose monitoring system (CGMS) was applied for 72 h. Continuous overlapping net glycemic action (CONGA), mean amplitude of glycemic excursion (MAGE), and mean of the daily differences (MODD) were calculated for the assessment of glycemic variability and compared with 1,5-AG. Urinary 8-iso prostaglandin F2α (8-isoPGF2α) was measured to assess oxidative stress. 1,5-AG was correlated with fasting blood glucose, HbA1c, postprandial area under the curve for glucose above 180 mg/dL (AUC-180), and mean post-meal maximum glucose (MPMG). However, 1,5-AG did not show significant correlation with CONGA-1, MAGE, and MODD (R = -0.053, P = 0.689; R = -0.148, P = 0.259; R = -0.123, P = 0.350). In patients with HbA1c ≤ 8.0% (n = 35), 1,5-AG was significantly correlated with HbA1c, mean glucose, postprandial AUC-180, and MPMG. However, in patients with HbA1c > 8.0% (n = 25), 1,5-AG did not show correlation with any glycemic markers. Oxidative stress measured as urine 8-isoPGF2α showed positive correlations with CONGA-1, MAGE, AUC-180, postprandial AUC-180, and MPMG only in men. However, 1,5-AG did not correlate with oxidative stress. Our data suggested a limited usefulness of 1,5-AG in estimating glycemic variability and oxidative stress. 1,5-AG was able to represent mean glucose and postprandial hyperglycemia only in well-controlled diabetic patients.
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Affiliation(s)
- Min Joo Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 28 Yongon-dong, Jongno-gu, Seoul, 110-744, Republic of Korea
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14
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McDonald TJ, Ellard S. Maturity onset diabetes of the young: identification and diagnosis. Ann Clin Biochem 2013; 50:403-15. [PMID: 23878349 DOI: 10.1177/0004563213483458] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Maturity-onset diabetes of the young (MODY) is a monogenic disorder that results in a familial, young-onset non-insulin dependent form of diabetes, typically presenting in lean young adults before 25 years. Approximately 1% of diabetes has a monogenic cause but this is frequently misdiagnosed as Type 1 or Type 2 diabetes. A correct genetic diagnosis is important as it often leads to improved treatment for those affected with diabetes and enables predictive genetic testing for their asymptomatic relatives. An early diagnosis together with appropriate treatment is essential for reducing the risk of diabetic complications in later life. Mutations in the GCK and HNF1A/4 A genes account for up to 80% of all MODY cases. Mutations in the GCK gene cause a mild, asymptomatic and non-progressive fasting hyperglycaemia from birth usually requiring no treatment. In contrast, mutations in the genes encoding the transcription factors HNF1A and HNF4A cause a progressive insulin secretory defect and hyperglycaemia that can lead to vascular complications. The diabetes in these patients is usually well controlled with sulphonylurea tablets although insulin treatment may be required in later life. In this review, we outline the key clinical and laboratory characteristics of the common and rarer causes of MODY with the aim of raising awareness of this condition amongst health-care scientists.
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Affiliation(s)
- Tim J McDonald
- Department of Clinical Biochemistry, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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15
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Steele AM, Wensley KJ, Ellard S, Murphy R, Shepherd M, Colclough K, Hattersley AT, Shields BM. Use of HbA1c in the identification of patients with hyperglycaemia caused by a glucokinase mutation: observational case control studies. PLoS One 2013; 8:e65326. [PMID: 23799006 PMCID: PMC3683003 DOI: 10.1371/journal.pone.0065326] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Accepted: 04/23/2013] [Indexed: 11/25/2022] Open
Abstract
AIMS HaemoglobinA1c (HbA1c) is recommended for diabetes diagnosis but fasting plasma glucose (FPG) has been useful for identifying patients with glucokinase (GCK) mutations which cause lifelong persistent fasting hyperglycaemia. We aimed to derive age-related HbA1c reference ranges for these patients to determine how well HbA1c can discriminate patients with a GCK mutation from unaffected family members and young-onset type 1 (T1D) and type 2 diabetes (T2D) and to investigate the proportion of GCK mutation carriers diagnosed with diabetes using HbA1c and/or FPG diagnostic criteria. METHODS Individuals with inactivating GCK mutations (n = 129), familial controls (n = 100), T1D (n = 278) and T2D (n = 319) aged ≥18years were recruited. Receiver Operating Characteristic (ROC) analysis determined effectiveness of HbA1c and FPG to discriminate between groups. RESULTS HbA1c reference ranges in subjects with GCK mutations were: 38-56 mmol/mol (5.6-7.3%) if aged ≤40years; 41-60 mmol/mol (5.9-7.6%) if >40years. All patients (123/123) with a GCK mutation were above the lower limit of the HbA1c age-appropriate reference ranges. 69% (31/99) of controls were below these lower limits. HbA1c was also effective in discriminating those with a GCK mutation from those with T1D/T2D. Using the upper limit of the age-appropriate reference ranges to discriminate those with a mutation from those with T1D/T2D correctly identified 97% of subjects with a mutation. The majority (438/597 (73%)) with other types of young-onset diabetes had an HbA1c above the upper limit of the age-appropriate GCK reference range. HbA1c ≥48 mmol/mol classified more people with GCK mutations as having diabetes than FPG ≥7 mmol/l (68% vs. 48%, p = 0.0009). CONCLUSIONS Current HbA1c diagnostic criteria increase diabetes diagnosis in patients with a GCK mutation. We have derived age-related HbA1c reference ranges that can be used for discriminating hyperglycaemia likely to be caused by a GCK mutation and aid identification of probands and family members for genetic testing.
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Affiliation(s)
- Anna M Steele
- NIHR Exeter Clinical Research Facility, University of Exeter, Exeter, Devon, United Kingdom.
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16
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Thanabalasingham G, Huffman JE, Kattla JJ, Novokmet M, Rudan I, Gloyn AL, Hayward C, Adamczyk B, Reynolds RM, Muzinic A, Hassanali N, Pucic M, Bennett AJ, Essafi A, Polasek O, Mughal SA, Redzic I, Primorac D, Zgaga L, Kolcic I, Hansen T, Gasperikova D, Tjora E, Strachan MW, Nielsen T, Stanik J, Klimes I, Pedersen OB, Njølstad PR, Wild SH, Gyllensten U, Gornik O, Wilson JF, Hastie ND, Campbell H, McCarthy MI, Rudd PM, Owen KR, Lauc G, Wright AF. Mutations in HNF1A result in marked alterations of plasma glycan profile. Diabetes 2013; 62:1329-37. [PMID: 23274891 PMCID: PMC3609552 DOI: 10.2337/db12-0880] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 10/17/2012] [Indexed: 12/31/2022]
Abstract
A recent genome-wide association study identified hepatocyte nuclear factor 1-α (HNF1A) as a key regulator of fucosylation. We hypothesized that loss-of-function HNF1A mutations causal for maturity-onset diabetes of the young (MODY) would display altered fucosylation of N-linked glycans on plasma proteins and that glycan biomarkers could improve the efficiency of a diagnosis of HNF1A-MODY. In a pilot comparison of 33 subjects with HNF1A-MODY and 41 subjects with type 2 diabetes, 15 of 29 glycan measurements differed between the two groups. The DG9-glycan index, which is the ratio of fucosylated to nonfucosylated triantennary glycans, provided optimum discrimination in the pilot study and was examined further among additional subjects with HNF1A-MODY (n = 188), glucokinase (GCK)-MODY (n = 118), hepatocyte nuclear factor 4-α (HNF4A)-MODY (n = 40), type 1 diabetes (n = 98), type 2 diabetes (n = 167), and nondiabetic controls (n = 98). The DG9-glycan index was markedly lower in HNF1A-MODY than in controls or other diabetes subtypes, offered good discrimination between HNF1A-MODY and both type 1 and type 2 diabetes (C statistic ≥ 0.90), and enabled us to detect three previously undetected HNF1A mutations in patients with diabetes. In conclusion, glycan profiles are altered substantially in HNF1A-MODY, and the DG9-glycan index has potential clinical value as a diagnostic biomarker of HNF1A dysfunction.
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Affiliation(s)
- Gaya Thanabalasingham
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, U.K
| | - Jennifer E. Huffman
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, U.K
| | - Jayesh J. Kattla
- Dublin-Oxford Glycobiology Laboratory, National Institute for Bioprocessing Research and Training (NIBRT), Dublin, Ireland
| | | | - Igor Rudan
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, U.K
- University of Split School of Medicine, Split, Croatia
| | - Anna L. Gloyn
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, U.K
| | - Caroline Hayward
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, U.K
| | - Barbara Adamczyk
- Dublin-Oxford Glycobiology Laboratory, National Institute for Bioprocessing Research and Training (NIBRT), Dublin, Ireland
| | - Rebecca M. Reynolds
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, University of Edinburgh, Edinburgh, U.K
| | - Ana Muzinic
- Genos Ltd., Glycobiology Division, Zagreb, Croatia
| | - Neelam Hassanali
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
| | - Maja Pucic
- Genos Ltd., Glycobiology Division, Zagreb, Croatia
| | - Amanda J. Bennett
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
| | - Abdelkader Essafi
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, U.K
| | - Ozren Polasek
- University of Split School of Medicine, Split, Croatia
| | - Saima A. Mughal
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, U.K
| | - Irma Redzic
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Dragan Primorac
- University of Split School of Medicine, Split, Croatia
- University of Osijek School of Medicine, Osijek, Croatia
| | - Lina Zgaga
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, U.K
| | - Ivana Kolcic
- University of Split School of Medicine, Split, Croatia
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center, Gentofte, Denmark
| | - Daniela Gasperikova
- DIABGENE and Diabetes Laboratory, Institute of Experimental Endocrinology, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Erling Tjora
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | | | - Trine Nielsen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Juraj Stanik
- DIABGENE and Diabetes Laboratory, Institute of Experimental Endocrinology, Slovak Academy of Sciences, Bratislava, Slovakia
- Children Diabetes Centre at the First Department of Paediatrics, Faculty of Medicine at the Comenius University, Bratislava, Slovakia
| | - Iwar Klimes
- DIABGENE and Diabetes Laboratory, Institute of Experimental Endocrinology, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Oluf B. Pedersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Faculty of Health Sciences, University of Aarhus, Aarhus, Denmark
- Hagedorn Research Institute, Copenhagen, Denmark
| | - Pål R. Njølstad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Sarah H. Wild
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, U.K
| | - Ulf Gyllensten
- Department of Genetics and Pathology, Rudbeck Laboratory, Uppsala University, Uppsala, Sweden
| | - Olga Gornik
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - James F. Wilson
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, U.K
| | - Nicholas D. Hastie
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, U.K
| | - Harry Campbell
- Centre for Population Health Sciences, University of Edinburgh Medical School, Edinburgh, U.K
| | - Mark I. McCarthy
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, U.K
- Wellcome Trust for Human Genetics, University of Oxford, Oxford, U.K
| | - Pauline M. Rudd
- Dublin-Oxford Glycobiology Laboratory, National Institute for Bioprocessing Research and Training (NIBRT), Dublin, Ireland
| | - Katharine R. Owen
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, U.K
| | - Gordan Lauc
- Genos Ltd., Glycobiology Division, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Zagreb, Croatia
| | - Alan F. Wright
- MRC Human Genetics Unit, Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, U.K
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Abstract
The measure of glycated hemoglobin (HbA1c) concentration is the gold standard of glycemic control index in diabetes management and is well known as a marker for diabetes complications. However, HbA1c level neither accurately reflect glucose fluctuations, nor does it provide a clear indication of glycemic control in recent days or weeks. HbA1c concentration measurement can be confounded in patients with anemia, hemoglobinopathy, liver disease, or renal impairment. 1,5-Anhydroglucitol (1,5-AG) structurally resembles glucose. It can be influenced by diet or medication, gender and race, especially severe renal disease and various pathological conditions. Most notably, 1,5-AG level is reflective of short-term glucose status, postprandial hyperglycemia, and glycemic variability which are not captured by HbA1c assay. 1,5-AG may suggest an alternative index of subtypes of diabetes and a warning sign of diabetes complications. This review provides an overview of our current understanding of the role of 1,5-AG marker in diabetes. However, further investigations on the associations between this glycemic marker and diabetes complications are needed.
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Affiliation(s)
- Won Jun Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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18
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Mughal SA, Thanabalasingham G, Owen KR. Biomarkers currently used for the diagnosis of maturity-onset diabetes of the young. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/dmt.12.82] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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19
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Gloyn AL, Faber JH, Malmodin D, Thanabalasingham G, Lam F, Ueland PM, McCarthy MI, Owen KR, Baunsgaard D. Metabolic profiling in Maturity-onset diabetes of the young (MODY) and young onset type 2 diabetes fails to detect robust urinary biomarkers. PLoS One 2012; 7:e40962. [PMID: 22859960 PMCID: PMC3408469 DOI: 10.1371/journal.pone.0040962] [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] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 06/15/2012] [Indexed: 11/18/2022] Open
Abstract
It is important to identify patients with Maturity-onset diabetes of the young (MODY) as a molecular diagnosis determines both treatment and prognosis. Genetic testing is currently expensive and many patients are therefore not assessed and are misclassified as having either type 1 or type 2 diabetes. Biomarkers could facilitate the prioritisation of patients for genetic testing. We hypothesised that patients with different underlying genetic aetiologies for their diabetes could have distinct metabolic profiles which may uncover novel biomarkers. The aim of this study was to perform metabolic profiling in urine from patients with MODY due to mutations in the genes encoding glucokinase (GCK) or hepatocyte nuclear factor 1 alpha (HNF1A), type 2 diabetes (T2D) and normoglycaemic control subjects. Urinary metabolic profiling by Nuclear Magnetic Resonance (NMR) and ultra performance liquid chromatography hyphenated to Q-TOF mass spectrometry (UPLC-MS) was performed in a Discovery set of subjects with HNF1A-MODY (n = 14), GCK-MODY (n = 17), T2D (n = 14) and normoglycaemic controls (n = 34). Data were used to build a valid partial least squares discriminate analysis (PLS-DA) model where HNF1A-MODY subjects could be separated from the other diabetes subtypes. No single metabolite contributed significantly to the separation of the patient groups. However, betaine, valine, glycine and glucose were elevated in the urine of HNF1A-MODY subjects compared to the other subgroups. Direct measurements of urinary amino acids and betaine in an extended dataset did not support differences between patients groups. Elevated urinary glucose in HNF1A-MODY is consistent with the previously reported low renal threshold for glucose in this genetic subtype. In conclusion, we report the first metabolic profiling study in monogenic diabetes and show that, despite the distinct biochemical pathways affected, there are unlikely to be robust urinary biomarkers which distinguish monogenic subtypes from T2D. Our results have implications for studies investigating metabolic profiles in complex traits including T2D.
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Affiliation(s)
- Anna L. Gloyn
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, Oxford, United Kingdom
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
| | | | | | - Gaya Thanabalasingham
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, Oxford, United Kingdom
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
| | - Francis Lam
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - Mark I. McCarthy
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, Oxford, United Kingdom
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Katharine R. Owen
- Oxford Centre for Diabetes, Endocrinology & Metabolism, University of Oxford, Oxford, United Kingdom
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
- * E-mail: (KRO); (DB)
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20
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Thanabalasingham G, Pal A, Selwood MP, Dudley C, Fisher K, Bingley PJ, Ellard S, Farmer AJ, McCarthy MI, Owen KR. Systematic assessment of etiology in adults with a clinical diagnosis of young-onset type 2 diabetes is a successful strategy for identifying maturity-onset diabetes of the young. Diabetes Care 2012; 35:1206-12. [PMID: 22432108 PMCID: PMC3357216 DOI: 10.2337/dc11-1243] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Accepted: 11/03/2011] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Misdiagnosis of maturity-onset diabetes of the young (MODY) remains widespread, despite the benefits of optimized management. This cross-sectional study examined diagnostic misclassification of MODY in subjects with clinically labeled young adult-onset type 1 and type 2 diabetes by extending genetic testing beyond current guidelines. RESEARCH DESIGN AND METHODS Individuals were selected for diagnostic sequencing if they displayed features atypical for their diagnostic label. From 247 case subjects with clinically labeled type 1 diabetes, we sequenced hepatocyte nuclear factor 1 α (HNF1A) and hepatocyte nuclear factor 4 α (HNF4A) in 20 with residual β-cell function ≥ 3 years from diagnosis (random or glucagon-stimulated C-peptide ≥ 0.2 nmol/L). From 322 with clinically labeled type 2 diabetes, we sequenced HNF1A and HNF4A in 80 with diabetes diagnosed ≤ 30 years and/or diabetes diagnosed ≤ 45 years without metabolic syndrome. We also sequenced the glucokinase (GCK) in 40 subjects with mild fasting hyperglycemia. RESULTS In the type 1 diabetic group, two HNF1A mutations were found (0.8% prevalence). In type 2 diabetic subjects, 10 HNF1A, two HNF4A, and one GCK mutation were identified (4.0%). Only 47% of MODY case subjects identified met current guidelines for diagnostic sequencing. Follow-up revealed a further 12 mutation carriers among relatives. Twenty-seven percent of newly identified MODY subjects changed treatment, all with improved glycemic control (HbA(1c) 8.8 vs. 7.3% at 3 months; P = 0.02). CONCLUSIONS The systematic use of widened diagnostic testing criteria doubled the numbers of MODY case subjects identified compared with current clinical practice. The yield was greatest in young adult-onset type 2 diabetes. We recommend that all patients diagnosed before age 30 and with presence of C-peptide at 3 years' duration are considered for molecular diagnostic analysis.
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Affiliation(s)
- Gaya Thanabalasingham
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, U.K
- Oxford National Institute for Health Research Biomedical Research Centre, Churchill Hospital, Oxford, U.K
| | - Aparna Pal
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, U.K
- Oxford National Institute for Health Research Biomedical Research Centre, Churchill Hospital, Oxford, U.K
| | - Mary P. Selwood
- Department of Primary Care Health Sciences, University of Oxford, Oxford, U.K
| | - Christina Dudley
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, U.K
- Oxford National Institute for Health Research Biomedical Research Centre, Churchill Hospital, Oxford, U.K
| | - Karen Fisher
- Nuffield Department of Clinical Laboratory Sciences, Oxford, U.K
| | - Polly J. Bingley
- Department of Clinical Science, University of Bristol, Bristol, U.K
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, Peninsula Medical School, University of Exeter, Exeter, U.K
| | - Andrew J. Farmer
- Oxford National Institute for Health Research Biomedical Research Centre, Churchill Hospital, Oxford, U.K
- Department of Primary Care Health Sciences, University of Oxford, Oxford, U.K
| | - Mark I. McCarthy
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, U.K
- Oxford National Institute for Health Research Biomedical Research Centre, Churchill Hospital, Oxford, U.K
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, U.K
| | - Katharine R. Owen
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, U.K
- Oxford National Institute for Health Research Biomedical Research Centre, Churchill Hospital, Oxford, U.K
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21
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Thanabalasingham G, Shah N, Vaxillaire M, Hansen T, Tuomi T, Gašperíková D, Szopa M, Tjora E, James TJ, Kokko P, Loiseleur F, Andersson E, Gaget S, Isomaa B, Nowak N, Raeder H, Stanik J, Njolstad PR, Malecki MT, Klimes I, Groop L, Pedersen O, Froguel P, McCarthy MI, Gloyn AL, Owen KR. A large multi-centre European study validates high-sensitivity C-reactive protein (hsCRP) as a clinical biomarker for the diagnosis of diabetes subtypes. Diabetologia 2011; 54:2801-10. [PMID: 21814873 DOI: 10.1007/s00125-011-2261-y] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 06/30/2011] [Indexed: 12/21/2022]
Abstract
AIMS/HYPOTHESIS An accurate molecular diagnosis of diabetes subtype confers clinical benefits; however, many individuals with monogenic diabetes remain undiagnosed. Biomarkers could help to prioritise patients for genetic investigation. We recently demonstrated that high-sensitivity C-reactive protein (hsCRP) levels are lower in UK patients with hepatocyte nuclear factor 1 alpha (HNF1A)-MODY than in other diabetes subtypes. In this large multi-centre study we aimed to assess the clinical validity of hsCRP as a diagnostic biomarker, examine the genotype-phenotype relationship and compare different hsCRP assays. METHODS High-sensitivity CRP levels were analysed in individuals with HNF1A-MODY (n = 457), glucokinase (GCK)-MODY (n = 404), hepatocyte nuclear factor 4 alpha (HNF4A)-MODY (n = 54) and type 2 diabetes (n = 582) from seven European centres. Three common assays for hsCRP analysis were evaluated. We excluded 121 participants (8.1%) with hsCRP values >10 mg/l. The discriminative power of hsCRP with respect to diabetes aetiology was assessed by receiver operating characteristic curve-derived C-statistic. RESULTS In all centres and irrespective of the assay method, meta-analysis confirmed significantly lower hsCRP levels in those with HNF1A-MODY than in those with other aetiologies (z score -21.8, p < 5 × 10(-105)). HNF1A-MODY cases with missense mutations had lower hsCRP levels than those with truncating mutations (0.03 vs 0.08 mg/l, p < 5 × 10(-5)). High-sensitivity CRP values between assays were strongly correlated (r (2) ≥ 0.91, p ≤ 1 × 10(-5)). Across the seven centres, the C-statistic for distinguishing HNF1A-MODY from young adult-onset type 2 diabetes ranged from 0.79 to 0.97, indicating high discriminative accuracy. CONCLUSIONS/INTERPRETATION In the largest study to date, we have established that hsCRP is a clinically valid biomarker for HNF1A-MODY in European populations. Given the modest costs and wide availability, hsCRP could translate rapidly into clinical practice, considerably improving diagnosis rates in monogenic diabetes.
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Affiliation(s)
- G Thanabalasingham
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Churchill Hospital, Headington, Oxford, OX3 7LJ, UK
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22
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Fendler W, Borowiec M, Antosik K, Szadkowska A, Deja G, Jarosz-Chobot P, Mysliwiec M, Wyka K, Pietrzak I, Skupien J, Malecki MT, Mlynarski W. HDL cholesterol as a diagnostic tool for clinical differentiation of GCK-MODY from HNF1A-MODY and type 1 diabetes in children and young adults. Clin Endocrinol (Oxf) 2011; 75:321-7. [PMID: 21521320 DOI: 10.1111/j.1365-2265.2011.04052.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Confirmation of monogenic diabetes caused by glucokinase mutations (GCK-MODY) allows pharmacogenetic intervention in the form of insulin discontinuation. This is especially important among paediatric and young adult populations where GCK-MODY is most prevalent. METHODS The study evaluated the utility of lipid parameters in screening for patients with GCK-MODY. Eighty-nine children with type 1 diabetes and 68 with GCK-MODY were screened for triglyceride (TG), total and HDL cholesterol levels. Standardization against a control group of 171 healthy children was applied to eliminate the effect of development. Clinical applicability and cut-off value were evaluated in all available patients with GCK-MODY (n = 148), hepatocyte nuclear factor 1-alpha-MODY (HNF1A MODY) (n = 37) or type 1 diabetes (n = 221). RESULTS Lower lipid parameter values were observed in GCK-MODY than in patients with type 1 diabetes. Standard deviation scores were -0·22 ± 2·24 vs 1·31 ± 2·17 for HDL cholesterol (P < 0·001), -0·16 ± 2·14 vs 0·60 ± 1·77 for total cholesterol (P = 0·03) and -0·57 ± 0·97 vs-0·22 ± 0·97 for TG (P = 0·05). Validation analysis confirmed that HDL cholesterol was the best parameter for GCK-MODY selection [sensitivity 87%, specificity 54%, negative predictive value (NPV) 86%, positive PV 56%]. A threshold HDL concentration of 1·56 mm offered significantly better diagnostic efficiency than total cholesterol (cut-off value 4·51 mm; NPV 80%; PPV 38%; P < 0·001). TG did not offer a meaningful cut-off value. CONCLUSIONS HDL cholesterol levels measured in individuals with likely monogenic diabetes may be useful in screening for GCK-MODY and differentiation from T1DM and HNF1A-MODY, regardless of treatment or metabolic control.
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Affiliation(s)
- Wojciech Fendler
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Lodz, Poland
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Abstract
Biomarkers for Diabetes Complications: The Results of Several Clinical StudiesDiabetes is a common metabolic disorder. Its microvascular and macrovascular complications contribute to death, disabilities, and reduction in life expectancy in diabetes. It is a costly disease, and affects not only the patient and family, but also the public health, communities and society. It takes an increasing proportion of the national health care expenditure. The prevention of the development of diabetes and its complications is a major concern. Biomarkers have been investigated for understanding the mechanisms of the development and progression of diabetic complications. In this paper, the biomarkers which are recommended in the clinical practice and laboratory medicine guidelines, and which have been investigated for prediction or diagnosis of diabetes complications, have been reviewed. The results of several clinical studies will be summarized.
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Selvin E, Steffes MW, Ballantyne CM, Hoogeveen RC, Coresh J, Brancati FL. Racial differences in glycemic markers: a cross-sectional analysis of community-based data. Ann Intern Med 2011; 154:303-9. [PMID: 21357907 PMCID: PMC3131743 DOI: 10.7326/0003-4819-154-5-201103010-00004] [Citation(s) in RCA: 147] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although differences between black and white persons in hemoglobin A(1c) (HbA(1c)) values are well established, recent studies suggest that this might not reflect differences in glycemia. OBJECTIVE To investigate racial disparities in glycemic markers, including those that reflect biological processes independent of hemoglobin glycation and erythrocyte turnover. DESIGN Cross-sectional. SETTING Community-based. PARTICIPANTS 1376 nondiabetic and 343 diabetic adults in a substudy of the Atherosclerosis Risk in Communities Study. MEASUREMENTS Hemoglobin A(1c), fasting glucose, glycated albumin, fructosamine, and 1,5-anhydroglucitol levels. RESULTS Among persons with and without diabetes, black persons had significantly higher HbA(1c), glycated albumin, and fructosamine levels than white persons before and after adjustment for covariates and fasting glucose concentration. Serum 1,5-anhydroglucitol levels, which are reduced in the setting of hyperglycemia-induced glycosuria, were lower in black persons than in white persons, although this difference was statistically significant only in nondiabetic adults. LIMITATION The design was cross-sectional, a limited number of participants with a history of diabetes was included, and the study did not include integrated measures of circulating nonfasting glycemia. CONCLUSION Differences between black and white persons in glycated albumin, fructosamine, and 1,5-anhydroglucitol levels parallel differences between these groups in HbA(1c) values. Racial differences in hemoglobin glycation and erythrocyte turnover cannot explain racial disparities in these serum markers. The possibility that black persons have systematically higher levels of nonfasting glycemia warrants further study. PRIMARY FUNDING SOURCE National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Elizabeth Selvin
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.
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Besser REJ, Shepherd MH, McDonald TJ, Shields BM, Knight BA, Ellard S, Hattersley AT. Urinary C-peptide creatinine ratio is a practical outpatient tool for identifying hepatocyte nuclear factor 1-{alpha}/hepatocyte nuclear factor 4-{alpha} maturity-onset diabetes of the young from long-duration type 1 diabetes. Diabetes Care 2011; 34:286-91. [PMID: 21270186 PMCID: PMC3024335 DOI: 10.2337/dc10-1293] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Hepatocyte nuclear factor 1-α (HNF1A)/hepatocyte nuclear factor 4-α (HNF4A) maturity-onset diabetes of the young (MODY) is frequently misdiagnosed as type 1 diabetes, and patients are inappropriately treated with insulin. Blood C-peptide can aid in the diagnosis of MODY, but practical reasons limit its widespread use. Urinary C-peptide creatinine ratio (UCPCR), a stable measure of endogenous insulin secretion, is a noninvasive alternative. We aimed to compare stimulated UCPCR in adults with HNF1A/4A MODY, type 1 diabetes, and type 2 diabetes. RESEARCH DESIGN AND METHODS Adults with diabetes for ≥ 5 years, without renal impairment, were studied (HNF1A MODY [n = 54], HNF4A MODY [n = 23], glucokinase MODY [n = 20], type 1 diabetes [n = 69], and type 2 diabetes [n = 54]). The UCPCR was collected in boric acid 120 min after the largest meal of the day and mailed for analysis. Receiver operating characteristic (ROC) curves were used to identify optimal UCPCR cutoffs to differentiate HNF1A/4A MODY from type 1 and type 2 diabetes. RESULTS UCPCR was lower in type 1 diabetes than HNF1A/4A MODY (median [interquartile range]) (<0.02 nmol/mmol [<0.02 to <0.02] vs. 1.72 nmol/mmol [0.98-2.90]; P < 0.0001). ROC curves showed excellent discrimination (area under curve [AUC] 0.98) and identified a cutoff UCPCR of ≥ 0.2 nmol/mmol for differentiating HNF1A/4A MODY from type 1 diabetes (97% sensitivity, 96% specificity). UCPCR was lower in HNF1A/4A MODY than in type 2 diabetes (1.72 nmol/mmol [0.98-2.90] vs. 2.47 nmol/mmol [1.4-4.13]); P = 0.007). ROC curves showed a weak distinction between HNF1A/4A MODY and type 2 diabetes (AUC 0.64). CONCLUSIONS UCPCR is a noninvasive outpatient tool that can be used to discriminate HNF1A and HNF4A MODY from long-duration type 1 diabetes. To differentiate MODY from type 1 diabetes of >5 years' duration, UCPCR could be used to determine whether genetic testing is indicated.
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Affiliation(s)
- Rachel E J Besser
- Peninsula National Institute for Health Research Clinical Research Facility, Peninsula Medical School, University of Exeter, Exeter, UK
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Selvin E, Rynders GP, Steffes MW. Comparison of two assays for serum 1,5-anhydroglucitol. Clin Chim Acta 2011; 412:793-5. [PMID: 21238440 DOI: 10.1016/j.cca.2011.01.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2011] [Revised: 01/06/2011] [Accepted: 01/06/2011] [Indexed: 01/11/2023]
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Malecki MT. The search for undiagnosed MODY patients: what is the next step? Diabetologia 2010; 53:2465-7. [PMID: 20865241 DOI: 10.1007/s00125-010-1908-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 08/23/2010] [Indexed: 11/28/2022]
Affiliation(s)
- M T Malecki
- Department of Metabolic Diseases, Jagiellonian University Medical College, 15 Kopernika Street, 31-501 Krakow, Poland.
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Owen KR, Thanabalasingham G, James TJ, Karpe F, Farmer AJ, McCarthy MI, Gloyn AL. Assessment of high-sensitivity C-reactive protein levels as diagnostic discriminator of maturity-onset diabetes of the young due to HNF1A mutations. Diabetes Care 2010; 33:1919-24. [PMID: 20724646 PMCID: PMC2928334 DOI: 10.2337/dc10-0288] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Despite the clinical importance of an accurate diagnosis in individuals with monogenic forms of diabetes, restricted access to genetic testing leaves many patients with undiagnosed diabetes. Recently, common variation near the HNF1 homeobox A (HNF1A) gene was shown to influence C-reactive protein levels in healthy adults. We hypothesized that serum levels of high-sensitivity C-reactive protein (hs-CRP) could represent a clinically useful biomarker for the identification of HNF1A mutations causing maturity-onset diabetes of the young (MODY). RESEARCH DESIGN AND METHODS Serum hs-CRP was measured in subjects with HNF1A-MODY (n = 31), autoimmune diabetes (n = 316), type 2 diabetes (n = 240), and glucokinase (GCK) MODY (n = 24) and in nondiabetic individuals (n = 198). The discriminative accuracy of hs-CRP was evaluated through receiver operating characteristic (ROC) curve analysis, and performance was compared with standard diagnostic criteria. Our primary analyses excluded approximately 11% of subjects in whom the single available hs-CRP measurement was >10 mg/l. RESULTS Geometric mean (SD range) hs-CRP levels were significantly lower (P <or= 0.009) for HNF1A-MODY individuals, 0.20 (0.03-1.14) mg/l, than for any other group: autoimmune diabetes 0.58 (0.10-2.75) mg/l, type 2 diabetes 1.33 (0.28-6.14) mg/l, GCK-MODY 1.01 (0.19-5.33) mg/l, and nondiabetic 0.48 (0.10-2.42) mg/l. The ROC-derived C-statistic for discriminating HNF1A-MODY and type 2 diabetes was 0.8. Measurement of hs-CRP, either alone or in combination with current diagnostic criteria, was superior to current diagnostic criteria alone. Sensitivity and specificity for the combined criteria approached 80%. CONCLUSIONS Serum hs-CRP levels are markedly lower in HNF1A-MODY than in other forms of diabetes. hs-CRP has potential as a widely available, cost-effective screening test to support more precise targeting of MODY diagnostic testing.
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Affiliation(s)
- Katharine R Owen
- Oxford Centre for Diabetes Endocrinology and Metabolism, University of Oxford, Oxford, U.K.
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