1
|
Larsen AR, Brusgaard K, Christesen HT, Detlefsen S. Genotype-histotype-phenotype correlations in hyperinsulinemic hypoglycemia. Histol Histopathol 2024; 39:817-844. [PMID: 38305063 DOI: 10.14670/hh-18-709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Hyperinsulinemic hypoglycemia (HH) of pancreatic origin includes congenital hyperinsulinism (CHI), insulinoma, insulinomatosis, and adult-onset non-insulinoma persistent hyperinsulinemic hypoglycemia syndrome (NI-PHHS). In this review, we describe the genotype-histotype-phenotype correlations in HH and their therapeutic implications. CHI can occur from birth or later on in life. Histologically, diffuse CHI shows diffuse beta cell hypertrophy with a few giant nuclei per islet of Langerhans, most frequently caused by loss-of-function mutations in ABCC8 or KCNJ11. Focal CHI is histologically characterized by focal adenomatous hyperplasia consisting of confluent hyperplastic islets, caused by a paternal ABCC8/KCNJ11 mutation combined with paternal uniparental disomy of 11p15. CHI in Beckwith-Wiedemann syndrome is caused by mosaic changes in the imprinting region 11p15.4-11p15.5, leading to segmental or diffuse overgrowth of endocrine tissue in the pancreas. Morphological mosaicism of pancreatic islets is characterized by occurence of hyperplastic (type 1) islets in one or a few lobules and small (type 2) islets in the entire pancreas. Other rare genetic causes of CHI show less characteristic or unspecific histology. HH with a predominant adult onset includes insulinomas, which are pancreatic insulin-producing endocrine neoplasms, in some cases with metastatic potential. Insulinomas occur sporadically or as part of multiple endocrine neoplasia type 1 due to MEN1 mutations. MAFA mutations may histologically lead to insulinomatosis with insulin-producing neuroendocrine microadenomas or neuroendocrine neoplasms. NI-PHHS is mainly seen in adults and shows slight histological changes in some patients, which have been defined as major and minor criteria. The genetic cause is unknown in most cases. The diagnosis of HH, as defined by genetic, histological, and phenotypic features, has important implications for patient management and outcome.
Collapse
Affiliation(s)
- Annette Rønholt Larsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Steno Diabetes Center, Odense University Hospital, Odense, Denmark
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark.
| |
Collapse
|
2
|
Roeper M, Hoermann H, Körner LM, Sobottka M, Mayatepek E, Kummer S, Meissner T. Transitional Neonatal Hypoglycemia and Adverse Neurodevelopment in Midchildhood. JAMA Netw Open 2024; 7:e243683. [PMID: 38530314 DOI: 10.1001/jamanetworkopen.2024.3683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/27/2024] Open
Abstract
Importance The circumstances under which neonatal hypoglycemia leads to brain damage remain unclear due to a lack of long-term data on the neurodevelopment of affected children. As a result, diagnostic strategies and treatment recommendations are inconsistent. Objective To evaluate whether the occurrence of severe transitional neonatal hypoglycemia (defined as having at least 1 blood glucose measurement of 30 mg/dL or below) is associated with adverse neurodevelopment in midchildhood. Design, Setting, and Participants This cohort study using neurodevelopmental testing of a retrospectively recruited cohort was conducted at a single-center tertiary hospital in Germany between March 2022 and February 2023. Children with neonatal blood glucose screening data were randomly selected from all births between 2010 and 2015. Frequency matching for sex, birth weight, gestational age, socioeconomic status, and primary risk factors for neonatal hypoglycemia was performed. Children with persistent hypoglycemia diseases or any risk factor for adverse neurodevelopment except hypoglycemia were excluded. Data were analyzed between February 2023 and March 2023. Exposure At least 1 neonatal hypoglycemia measurement with blood glucose measuring 30 mg/dL or below vs all measured blood glucose levels above 30 mg/dL during postnatal blood glucose screening starting on the first day of life. Main Outcomes and Measures Cognitive function measured by full-scale IQ test. Secondary outcomes included standardized scales of motor, visual, and executive functions, and child behavior, each measured at ages 7 to 11 years. Results A total of 140 children (mean [SD] age 9.1 [1.3] years; 77 male [55.0%]) participated in the study. Children with severe neonatal hypoglycemia had a 4.8 points lower mean full-scale IQ than controls (107.0 [95% CI, 104.0-109.9] vs 111.8 [95% CI, 108.8-114.8]). They showed a 4.9-fold (95% CI, 1.5-15.5) increased odds of abnormal fine motor function and a 5.3-fold (95% CI, 2.1-13.3) increased odds of abnormal visual-motor integration. Significantly higher T scores for attention problems (58.2 [95% CI, 56.1-60.2] vs 54.6 [95% CI, 52.6-56.6]) and attention-deficit/hyperactivity disorder symptoms (58.2 [95% CI, 56.2-60.2] vs 54.7 [95% CI, 52.8-56.7]) were reported by parents. Conclusions and Relevance Neonatal hypoglycemia with blood glucose levels of 30 mg/dL or below was associated with an increased risk for suboptimal neurodevelopmental outcomes in midchildhood. These findings imply that treatment strategies should aim to prevent episodes of hypoglycemia at these severely low levels.
Collapse
Affiliation(s)
- Marcia Roeper
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Henrike Hoermann
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Lisa M Körner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Marvin Sobottka
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Sebastian Kummer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| |
Collapse
|
3
|
Sivasubramanian M, Avari P, Gilbert C, Doodson L, Morgan K, Oliver N, Shah P. Accuracy and impact on quality of life of real-time continuous glucose monitoring in children with hyperinsulinaemic hypoglycaemia. Front Endocrinol (Lausanne) 2023; 14:1265076. [PMID: 37822600 PMCID: PMC10562688 DOI: 10.3389/fendo.2023.1265076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 08/31/2023] [Indexed: 10/13/2023] Open
Abstract
Objective Continuous glucose monitoring (CGM) is the standard of care for glucose monitoring in children with diabetes, however there are limited data reporting their use in hyperinsulinaemic hypoglycaemia (HH). Here, we evaluate CGM accuracy and its impact on quality of life in children with HH. Methods Real-time CGM (Dexcom G5 and G6) was used in children with HH aged 0-16years. Data from self-monitoring capillary blood glucose (CBG) and CGM were collected over a period of up to 28days and analysed. Quality of life was assessed by the PedsQL4.0 general module and PedsQL2.0 family impact module, completed by children and their parents/carers before and after CGM insertion. Analysis of accuracy metrics included mean absolute relative difference (MARD) and proportion of CGM values within 15, 20, and 30% or 15, 20, and 30 mg/dL of reference glucose values >100 mg/dL or ≤100 mg/dL, respectively (% 15/15, % 20/20, % 30/30). Clinical reliability was assessed with Clarke error grid (CEG) analyses. Results Prospective longitudinal study with data analysed from 40 children. The overall MARD between reference glucose and paired CGM values (n=4,928) was 13.0% (Dexcom G5 12.8%, Dexcom G6 13.1%). The proportion of readings meeting %15/15 and %20/20 were 77.3% and 86.4%, respectively, with CEG analysis demonstrating 97.4% of all values in zones A and B. Within the hypoglycaemia range (<70 mg/dL), the median ARD was 11.4% with a sensitivity and specificity of 64.2% and 91.3%, respectively. Overall PedsQL child report at baseline and endpoint were 57.6 (50.5 - 75.8) and 87.0 (82.9 - 91.2), and for parents were 60.3 (44.8 - 66.0) and 85.3 (83.7 - 91.3), respectively (both p<0.001). Conclusion Use of CGM for children with HH is feasible, with clinically acceptable accuracy, particularly in the hypoglycaemic range. Quality of life measures demonstrate significant improvement after CGM use. These data are important to explore use of CGM in disease indications, including neonatal and paediatric diabetes, cystic fibrosis and glycogen storage disorders.
Collapse
Affiliation(s)
- Madhini Sivasubramanian
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- University College London, Institute of Child Health, London, United Kingdom
- Faculty of Health and Wellbeing, University of Sunderland in London, London, United Kingdom
| | - Parizad Avari
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Clare Gilbert
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Louise Doodson
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Kate Morgan
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, United Kingdom
| | - Pratik Shah
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- University College London, Institute of Child Health, London, United Kingdom
- Department of Paediatric Endocrinology, The Royal London Children’s Hospital, Barts Health NHS Trust, London, United Kingdom
| |
Collapse
|
4
|
Alam KA, Svalastoga P, Martinez A, Glennon JC, Haavik J. Potassium channels in behavioral brain disorders. Molecular mechanisms and therapeutic potential: A narrative review. Neurosci Biobehav Rev 2023; 152:105301. [PMID: 37414376 DOI: 10.1016/j.neubiorev.2023.105301] [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: 03/31/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023]
Abstract
Potassium channels (K+-channels) selectively control the passive flow of potassium ions across biological membranes and thereby also regulate membrane excitability. Genetic variants affecting many of the human K+-channels are well known causes of Mendelian disorders within cardiology, neurology, and endocrinology. K+-channels are also primary targets of many natural toxins from poisonous organisms and drugs used within cardiology and metabolism. As genetic tools are improving and larger clinical samples are being investigated, the spectrum of clinical phenotypes implicated in K+-channels dysfunction is rapidly expanding, notably within immunology, neurosciences, and metabolism. K+-channels that previously were considered to be expressed in only a few organs and to have discrete physiological functions, have recently been found in multiple tissues and with new, unexpected functions. The pleiotropic functions and patterns of expression of K+-channels may provide additional therapeutic opportunities, along with new emerging challenges from off-target effects. Here we review the functions and therapeutic potential of K+-channels, with an emphasis on the nervous system, roles in neuropsychiatric disorders and their involvement in other organ systems and diseases.
Collapse
Affiliation(s)
| | - Pernille Svalastoga
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway; Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | | | - Jeffrey Colm Glennon
- Conway Institute for Biomolecular and Biomedical Research, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Jan Haavik
- Department of Biomedicine, University of Bergen, Norway; Division of Psychiatry, Haukeland University Hospital, Norway.
| |
Collapse
|
5
|
Roeper M, Hoermann H, Kummer S, Meissner T. Neonatal hypoglycemia: lack of evidence for a safe management. Front Endocrinol (Lausanne) 2023; 14:1179102. [PMID: 37361517 PMCID: PMC10285477 DOI: 10.3389/fendo.2023.1179102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 05/26/2023] [Indexed: 06/28/2023] Open
Abstract
Neonatal hypoglycemia affects up to 15% of all newborns. Despite the high prevalence there is no uniform definition of neonatal hypoglycemia, and existing guidelines differ significantly in terms of when and whom to screen for hypoglycemia, and where to set interventional thresholds and treatment goals. In this review, we discuss the difficulties to define hypoglycemia in neonates. Existing knowledge on different strategies to approach this problem will be reviewed with a focus on long-term neurodevelopmental outcome studies and results of interventional trials. Furthermore, we compare existing guidelines on the screening and management of neonatal hypoglycemia. We summarize that evidence-based knowledge about whom to screen, how to screen, and how to manage neonatal hypoglycemia is limited - particularly regarding operational thresholds (single values at which to intervene) and treatment goals (what blood glucose to aim for) to reliably prevent neurodevelopmental sequelae. These research gaps need to be addressed in future studies, systematically comparing different management strategies to progressively optimize the balance between prevention of neurodevelopmental sequelae and the burden of diagnostic or therapeutic procedures. Unfortunately, such studies are exceptionally challenging because they require large numbers of participants to be followed for years, as mild but relevant neurological consequences may not become apparent until mid-childhood or even later. Until there is clear, reproducible evidence on what blood glucose levels may be tolerated without negative impact, the operational threshold needs to include some safety margin to prevent potential long-term neurocognitive impairment from outweighing the short-term burden of hypoglycemia prevention during neonatal period.
Collapse
|
6
|
Саракаева ЛР, Рыжкова ДВ, Митрофанова ЛБ, Баиров ВГ, Сухоцкая АА, Смородин АП, Ефтич ЕА, Кельмансон ИА, Никитина ИЛ. [Electroencephalogram features in children with congenital hyperinsulinism treated according to the international protocol in Russian Federation]. PROBLEMY ENDOKRINOLOGII 2023; 69:68-75. [PMID: 36842080 PMCID: PMC9978872 DOI: 10.14341/probl13174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/03/2022] [Indexed: 02/27/2023]
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) is a rare life-threatening disease characterised by persistent hypoglycaemia as a result of inappropriate insulin secretion, which can lead to irreversible neurological defects in infants. AIM To evaluate neurophysiological characteristics of central nervous system in children with congenital hyperinsulinism treated according to the international protocol in Russian Federation. MATERIALS AND METHODS Our retrospective, prospective cohort study included 73 patients who received treatment for CHI according to the current international protocol at different departments of the Almazov National Medical Research Centre from 2017 to 2022. All patients underwent a comprehensive examination, including electroencephalography (EEG). RESULTS Among 73 patients with CHI, 35% (23) had focal form of the disease, 65% had non-focal form (49% (39) - diffuse form, 16% (11) - atypical form). All patients with focal form of CHI had a recovery as an outcome.Analysing the EEG data we found that paroxysmal activity was recorded in 23 patients (32%), 50 patients did not have paroxysmal activity (68%). Diffuse changes were observed in 47 patients (64%), whereas 26 patients (36%) were absent of it. By constructing Kaplan-Meier curves we found that the alpha rhythm is formed significantly (p=0.026) earlier in patients with a focal form of CHI. CONCLUSION CHI patients treated according to the international guidelines in Russian Federation show rather positive neurological outcome. We established that alpha rhythm earliest formation is associated with focal form of CHI.
Collapse
Affiliation(s)
- Л. Р. Саракаева
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | - Д. В. Рыжкова
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | | | - В. Г. Баиров
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | - А. А. Сухоцкая
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | - А. П. Смородин
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | - Е. А. Ефтич
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | - И. А. Кельмансон
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | - И. Л. Никитина
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| |
Collapse
|
7
|
Hopkins JJ, Childs AJ, Houghton JAL, Hewat TI, Atapattu N, Johnson MB, Patel KA, Laver TW, Flanagan SE. Hyperinsulinemic Hypoglycemia Diagnosed in Childhood Can Be Monogenic. J Clin Endocrinol Metab 2023; 108:680-687. [PMID: 36239000 PMCID: PMC9931180 DOI: 10.1210/clinem/dgac604] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/05/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Congenital hyperinsulinism (HI) is characterized by inappropriate insulin secretion despite low blood glucose. Persistent HI is often monogenic, with the majority of cases diagnosed in infancy. Less is known about the contribution of monogenic forms of disease in those presenting in childhood. OBJECTIVE We investigated the likelihood of finding a genetic cause in childhood-onset HI and explored potential factors leading to later age at presentation of disease. METHODS We screened known disease-causing genes in 1848 individuals with HI, referred for genetic testing as part of routine clinical care. Individuals were classified as infancy-onset (diagnosed with HI < 12 months of age) or childhood-onset (diagnosed at age 1-16 years). We assessed clinical characteristics and the genotypes of individuals with monogenic HI diagnosed in childhood to gain insights into the later age at diagnosis of HI in these children. RESULTS We identified the monogenic cause in 24% (n = 42/173) of the childhood-onset HI cohort; this was significantly lower than the proportion of genetic diagnoses in infancy-onset cases (74.5% [n = 1248/1675], P < 0.00001). Most (75%) individuals with genetically confirmed childhood-onset HI were diagnosed before 2.7 years, suggesting these cases represent the tail end of the normal distribution in age at diagnosis. This is supported by the finding that 81% of the variants identified in the childhood-onset cohort were detected in those diagnosed in infancy. CONCLUSION We have shown that monogenic HI is an important cause of hyperinsulinism presenting outside of infancy. Genetic testing should be considered in children with persistent hyperinsulinism, regardless of age at diagnosis.
Collapse
Affiliation(s)
| | | | - Jayne A L Houghton
- The Genomics Laboratory, Royal Devon University Healthcare NHS foundation Trust, Exeter EX2 5DW, UK
| | - Thomas I Hewat
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Navoda Atapattu
- Paediatric Endocrinology, Lady Ridgeway Hospital, Colombo 00800, Sri Lanka
| | - Matthew B Johnson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Kashyap A Patel
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
- The Genomics Laboratory, Royal Devon University Healthcare NHS foundation Trust, Exeter EX2 5DW, UK
| | - Thomas W Laver
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Sarah E Flanagan
- Correspondence: Dr. Sarah E. Flanagan, Associate Professor in Genomic Medicine, RILD Building, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK.
| |
Collapse
|
8
|
Hoermann H, Roeper M, Dafsari RS, Koestner F, Schneble D, von Zezschwitz D, Mayatepek E, Kummer S, Meissner T. Protecting against brain damage by improving treatment in neonates with hypoglycaemia: ProBrain-D-a study protocol of a prospective longitudinal study. BMJ Open 2022; 12:e063009. [PMID: 35985774 PMCID: PMC9396170 DOI: 10.1136/bmjopen-2022-063009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Although neonatal hypoglycaemia is the most common metabolic problem in neonates, there is no standard guideline for screening. Additionally, treatment of neonatal hypoglycaemia and glucose administration thresholds are discussed controversially. Severe hypoglycaemia can lead to brain damage, but data on the effects of mild hypoglycaemia on neurological development are limited. To our knowledge, this is the first prospective longitudinal cohort study to analyse if the implementation of a new diagnosis and treatment standard for neonatal hypoglycaemia may improve the outcome of neonates at risk for hypoglycaemia, especially concerning neurodevelopment. Furthermore, the acceptance and feasibility of the standard among different professional groups and parents are analysed. METHODS AND ANALYSIS After implementation of a structured standard operating procedure (SOP), detailing preventive measures, blood glucose screening and neonatal hypoglycaemia treatment in a tertiary care hospital, 678 neonates ≥35+0 weeks of gestation will be recruited in a monocentric prospective cohort study. For comparison, 139 children born before the implementation of this new SOP, who had risk factors for neonatal hypoglycaemia or qualified for blood glucose measurements are recruited (retrospective cohort). For the primary end point, comparative analyses between and within the prospective and retrospective cohorts will be performed regarding the neurological outcome at 2-2.5 years of age in Bayley Scales of Infant Development. Furthermore, comprehensive clinical data and data on nutrition and developmental milestones are assessed at different time points (6 weeks, 6, 12, 18 and 24 months) in the prospective cohort. Acceptance and feasibility of the new standard are assessed using questionnaires. ETHICS AND DISSEMINATION The study has been approved by the Ethics Committee of the Medical Faculty of the Heinrich-Heine-University Düsseldorf (20201162). The results of this study will be disseminated through peer-reviewed journals and presented at international conferences. TRIAL REGISTRATION NUMBER DRKS00024086.
Collapse
Affiliation(s)
- Henrike Hoermann
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Marcia Roeper
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Roschan Salimi Dafsari
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Felix Koestner
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Dominik Schneble
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Dunja von Zezschwitz
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Ertan Mayatepek
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Sebastian Kummer
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Thomas Meissner
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| |
Collapse
|
9
|
Kummer S, Rinné S, Seemann G, Bachmann N, Timothy K, Thornton PS, Pillekamp F, Mayatepek E, Bergmann C, Meissner T, Decher N. Hyperinsulinemic Hypoglycemia Associated with a CaV1.2 Variant with Mixed Gain- and Loss-of-Function Effects. Int J Mol Sci 2022; 23:ijms23158097. [PMID: 35897673 PMCID: PMC9332183 DOI: 10.3390/ijms23158097] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/16/2022] Open
Abstract
The voltage-dependent L-type calcium channel isoform CaV1.2 is critically involved in many physiological processes, e.g., in cardiac action potential formation, electromechanical coupling and regulation of insulin secretion by beta cells. Gain-of-function mutations in the calcium voltage-gated channel subunit alpha 1 C (CACNA1C) gene, encoding the CaV1.2 α1-subunit, cause Timothy syndrome (TS), a multisystemic disorder that includes autism spectrum disorders and long QT (LQT) syndrome. Strikingly, TS patients frequently suffer from hypoglycemia of yet unproven origin. Using next-generation sequencing, we identified a novel heterozygous CACNA1C mutation in a patient with congenital hyperinsulinism (CHI) and associated hypoglycemic episodes. We characterized the electrophysiological phenotype of the mutated channel using voltage-clamp recordings and in silico action potential modeling experiments. The identified CaV1.2L566P mutation causes a mixed electrophysiological phenotype of gain- and loss-of-function effects. In silico action potential modeling supports that this mixed electrophysiological phenotype leads to a tissue-specific impact on beta cells compared to cardiomyocytes. Thus, CACNA1C variants may be associated with non-syndromic hyperinsulinemic hypoglycemia without long-QT syndrome, explained by very specific electrophysiological properties of the mutated channel. We discuss different biochemical characteristics and clinical impacts of hypoglycemia in the context of CACNA1C variants and show that these may be associated with significant morbidity for Timothy Syndrome patients. Our findings underline that the potential of hypoglycemia warrants careful attention in patients with CACNA1C variants, and such variants should be included in the differential diagnosis of non-syndromic congenital hyperinsulinism.
Collapse
Affiliation(s)
- Sebastian Kummer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children’s Hospital, 40225 Duesseldorf, Germany; (F.P.); (E.M.); (T.M.)
- Correspondence: (S.K.); (N.D.); Tel.: +49-211-81-17001 (S.K.); +49-6421-2862148 (N.D.)
| | - Susanne Rinné
- Institute of Physiology and Pathophysiology, Vegetative Physiology, University of Marburg, 35043 Marburg, Germany;
| | - Gunnar Seemann
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg—Bad Krozingen, Medical Center—University of Freiburg, 79085 Freiburg im Breisgau, Germany;
| | - Nadine Bachmann
- Medizinische Genetik Mainz, Limbach Genetics, 55128 Mainz, Germany; (N.B.); (C.B.)
| | - Katherine Timothy
- Children’s Hospital Boston, Harvard Medical School, Boston, MA 02115, USA;
| | - Paul S. Thornton
- Division of Endocrinology and Diabetes, Cook Children’s Medical Center, Fort Worth, TX 76104, USA;
| | - Frank Pillekamp
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children’s Hospital, 40225 Duesseldorf, Germany; (F.P.); (E.M.); (T.M.)
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children’s Hospital, 40225 Duesseldorf, Germany; (F.P.); (E.M.); (T.M.)
| | - Carsten Bergmann
- Medizinische Genetik Mainz, Limbach Genetics, 55128 Mainz, Germany; (N.B.); (C.B.)
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children’s Hospital, 40225 Duesseldorf, Germany; (F.P.); (E.M.); (T.M.)
| | - Niels Decher
- Institute of Physiology and Pathophysiology, Vegetative Physiology, University of Marburg, 35043 Marburg, Germany;
- Correspondence: (S.K.); (N.D.); Tel.: +49-211-81-17001 (S.K.); +49-6421-2862148 (N.D.)
| |
Collapse
|
10
|
Heckmann M, Wudy SA. Light on the horizon? Will Continuous Glucose Monitoring Allow for Better Management of Congenital Hyperinsulinism? J Clin Endocrinol Metab 2022; 107:e1305-e1307. [PMID: 34612483 PMCID: PMC8852229 DOI: 10.1210/clinem/dgab720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Matthias Heckmann
- Department of Neonatology and Pediatric Intensive Care, University Medicine Greifswald, 17475 Greifswald, Germany
- Correspondence: Matthias Heckmann, MD, Department of Neonatology and Paediatric Intensive Care, University Medicine Greifswald, Ferdinand-Sauerbruchstraße, 17475 Greifswald, Germany. E-mail:
| | - Stefan A Wudy
- Paediatric Endocrinology & Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, 35435 Giessen, Germany
| |
Collapse
|
11
|
F-18 DOPA PET/CT in pediatric patients with hyperinsulinemic hypoglycemia: A correlation with genetic analysis. Nucl Med Commun 2022; 43:451-457. [PMID: 35045547 DOI: 10.1097/mnm.0000000000001526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM Persistent hyperinsulinemic hypoglycemia is a rare but life-threatening disease of infancy and childhood. 18F-DOPA PET/CT has been shown to be a useful modality in the localization of focal pancreatic lesions in these patients. We aimed to assess the role of 18F-DOPA PET/CT in such patients at our institution. MATERIALS AND METHODS In this prospective study, 18F-DOPA PET/CT scans and clinical details of 20 children with clinical diagnosis of hyperinsulinemic hypoglycemia were reviewed. Scans were acquired at 5 min postinjection of 2-3 mCi of 18F-DOPA on dedicated PET/CT scanners (Biograph mCT, Siemens Inc and Discovery PET/CT, GE). Abdominal spot images over 1-2 bed positions were acquired. Additionally, genetic mutation status, where available, was correlated to the scan findings. RESULTS Out of 20 children (7 female and 13 male), 13 were infants. The age of the children ranged from 3 months to 8 years. Fifteen children had undergone gene analysis, 12 were positive for mutation in ABCC8, 1 for GLUD-1, 1 for GCK mutations and 1 had not shown any mutation. 18F-DOPA PET/CT scan showed 5 focal pancreatic lesions in 5 children (1 in each), two focal lesions in 1 child and diffuse pancreatic uptake in 14 children. CONCLUSION 18F-DOPA PET/CT is a useful modality for localizing focal pancreatic lesions in children with persistent hyperinsulinemic hypoglycemia. The detection rate is significantly higher in patients with ABCC8 paternal monoallelic recessive gene mutation. 18F-DOPA PET/CT scan consequent to findings on genetic analysis appears to be useful in planning the management of children with hyperinsulinism.
Collapse
|
12
|
Auckburally SH, Worth C, Salomon-Estebanez M, Nicholson J, Harper S, Nutter PW, Banerjee I. Families' Experiences of Continuous Glucose Monitoring in the Management of Congenital Hyperinsulinism: A Thematic Analysis. Front Endocrinol (Lausanne) 2022; 13:894559. [PMID: 35928891 PMCID: PMC9343578 DOI: 10.3389/fendo.2022.894559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND AND AIMS In patients with congenital hyperinsulinism (CHI), recurrent hypoglycaemia can lead to longstanding neurological impairments. At present, glycaemic monitoring is with intermittent fingerprick blood glucose testing but this lacks utility to identify patterns and misses hypoglycaemic episodes between tests. Although continuous glucose monitoring (CGM) is well established in type 1 diabetes, its use has only been described in small studies in patients with CHI. In such studies, medical perspectives have been provided without fully considering the views of families using CGM. In this qualitative study, we aimed to explore families' experiences of using CGM in order to inform future clinical strategies for the management of CHI. METHODS Ten patients with CHI in a specialist centre used CGM for twelve weeks. All were invited to participate. Semi-structured interviews were conducted with nine families in whom patient ages ranged between two and seventeen years. Transcripts of the audio-recorded interviews were analysed using an inductive thematic analysis method. RESULTS Analysis revealed five core themes: CGM's function as an educational tool; behavioural changes; positive experiences; negative experiences; and design improvements. Close monitoring and retrospective analysis of glucose trends allowed for enhanced understanding of factors that influenced glucose levels at various times of the day. Parents noted more hypoglycaemic episodes than previously encountered through fingerprick tests; this new knowledge prompted modification of daily routines to prevent and improve the management of hypoglycaemia. CGM use was viewed favourably as offering parental reassurance, reduced fingerprick tests and predictive warnings. However, families also reported unfavourable aspects of alarms and questionable accuracy at low glucose levels. Adolescents were frustrated by the short proximity range for data transmission resulting in the need to always carry a separate receiver. Overall, families were positive about the use of CGM but expected application to be tailored to their child's medical condition. CONCLUSIONS Patients and families with CHI using CGM noticed trends in glucose levels which motivated behavioural changes to reduce hypoglycaemia with advantages outweighing disadvantages. They expected CHI-specific modifications to enhance utility. Future design of CGM should incorporate end users' opinions and experiences for optimal glycaemic monitoring of CHI.
Collapse
Affiliation(s)
- Sameera Hannah Auckburally
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- Faculty of Health and Medicine, Lancaster University, Lancaster, United Kingdom
- *Correspondence: Sameera Hannah Auckburally,
| | - Chris Worth
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- Department of Computer Science, University of Manchester, Manchester, United Kingdom
| | - Maria Salomon-Estebanez
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Jacqueline Nicholson
- Paediatric Psychosocial Service, Royal Manchester Children’s Hospital, Manchester, United Kingdom
| | - Simon Harper
- Department of Computer Science, University of Manchester, Manchester, United Kingdom
| | - Paul W. Nutter
- Department of Computer Science, University of Manchester, Manchester, United Kingdom
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children’s Hospital, Manchester, United Kingdom
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| |
Collapse
|
13
|
Hewat TI, Johnson MB, Flanagan SE. Congenital Hyperinsulinism: Current Laboratory-Based Approaches to the Genetic Diagnosis of a Heterogeneous Disease. Front Endocrinol (Lausanne) 2022; 13:873254. [PMID: 35872984 PMCID: PMC9302115 DOI: 10.3389/fendo.2022.873254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 06/14/2022] [Indexed: 11/17/2022] Open
Abstract
Congenital hyperinsulinism is characterised by the inappropriate release of insulin during hypoglycaemia. This potentially life-threatening disorder can occur in isolation, or present as a feature of syndromic disease. Establishing the underlying aetiology of the hyperinsulinism is critical for guiding medical management of this condition especially in children with diazoxide-unresponsive hyperinsulinism where the underlying genetics determines whether focal or diffuse pancreatic disease is present. Disease-causing single nucleotide variants affecting over 30 genes are known to cause persistent hyperinsulinism with mutations in the KATP channel genes (ABCC8 and KCNJ11) most commonly identified in children with severe persistent disease. Defects in methylation, changes in chromosome number, and large deletions and duplications disrupting multiple genes are also well described in congenital hyperinsulinism, further highlighting the genetic heterogeneity of this condition. Next-generation sequencing has revolutionised the approach to genetic testing for congenital hyperinsulinism with targeted gene panels, exome, and genome sequencing being highly sensitive methods for the analysis of multiple disease genes in a single reaction. It should though be recognised that limitations remain with next-generation sequencing with no single application able to detect all reported forms of genetic variation. This is an important consideration for hyperinsulinism genetic testing as comprehensive screening may require multiple investigations.
Collapse
|
14
|
Roeper M, Hoermann H, Salimi Dafsari R, Koestner F, Mayatepek E, Kummer S, Reinauer C, Meissner T. Anxiety, depression, and quality of life in parents of children with congenital hyperinsulinism. Eur J Pediatr 2022; 181:2779-2788. [PMID: 35507217 PMCID: PMC9192457 DOI: 10.1007/s00431-022-04486-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/11/2022] [Accepted: 04/22/2022] [Indexed: 11/03/2022]
Abstract
This study aimed to assess mental health, family burden, and quality of life (PQoL) in parents of children with persistent congenital hyperinsulinism (CHI). Forty-eight individual CHI parents (75% female) completed self-reported questionnaires and screening tools for anxiety (GAD-7), depression (PHQ-8), PQoL (ULQIE), and family burden (FaBeL). Additional data on sociodemographics, social support, and child- and disease-related data were recorded. 29.8% of parents showed major depressive symptoms and 38.3% had a probable general anxiety disorder, including 20.8% who had both. The family burden was moderate and assessment of PQoL yielded average scores. Neurological impairment in an affected child (p = .002 and p < .001, respectively) and lower working hours (p = .001 and p = .012, respectively) were the strongest predictors of worse GAD-7 and PHQ-8 scores. Furthermore, lower working hours (p = .012) and comorbidities in the affected child (p = .007) were significantly associated with lower PQoL. Mothers had worse GAD-7 scores (p = .006) and lower PQoL (p = .035) than fathers. Indication of sleep disturbance was associated with worse PHQ-8 scores (p = .003), higher family burden (p = .039), and reduced PQoL (p = .003). A higher number of caretakers besides parents was associated with decreased family burden (p = .019), improved PQoL (p < .001), and lower scores for anxiety (p = .016) and depressive (p = .021) symptoms. Conclusion: Symptoms of depression and anxiety are alarmingly prevalent in parents of children with CHI. Psychological screening of parents should be initiated to ensure early identification of psychological strains and psychosocial support should be offered as needed. A good support network and regular work activities can improve parental mental health and well-being. What is Known: • Psychosocial strains and reduced quality of life are common in parents of chronically ill children. What is New: • In this first study evaluating mental health, family burden, and quality of life in parents of children with congenital hyperinsulinism (CHI), symptoms of depression and anxiety were alarmingly prevalent. • Parents of children with CHI should receive regular psychological screening and psychosocial support should be offered as needed. A good support network and regular work activities can improve parental mental health and well-being.
Collapse
Affiliation(s)
- Marcia Roeper
- grid.411327.20000 0001 2176 9917Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Children’s Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Henrike Hoermann
- grid.411327.20000 0001 2176 9917Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Children’s Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Roschan Salimi Dafsari
- grid.411327.20000 0001 2176 9917Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Children’s Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Felix Koestner
- grid.411327.20000 0001 2176 9917Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Children’s Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Ertan Mayatepek
- grid.411327.20000 0001 2176 9917Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Children’s Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Sebastian Kummer
- grid.411327.20000 0001 2176 9917Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Children’s Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Christina Reinauer
- grid.411327.20000 0001 2176 9917Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Children’s Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Children's Hospital Düsseldorf, Heinrich-Heine-University, Moorenstr. 5, 40225, Düsseldorf, Germany.
| |
Collapse
|
15
|
Lithovius V, Otonkoski T. Stem Cell Based Models in Congenital Hyperinsulinism - Perspective on Practicalities and Possibilities. Front Endocrinol (Lausanne) 2022; 13:837450. [PMID: 35250887 PMCID: PMC8895269 DOI: 10.3389/fendo.2022.837450] [Citation(s) in RCA: 1] [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: 12/16/2021] [Accepted: 01/27/2022] [Indexed: 12/31/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a severe inherited neonatal disorder characterized by inappropriate insulin secretion caused by genetic defects of the pancreatic beta cells. Several open questions remain in CHI research, such as the optimal treatment for the most common type of CHI, caused by mutations in the genes encoding ATP-sensitive potassium channels, and the molecular mechanisms of newly identified CHI genes. Answering these questions requires robust preclinical models, particularly since primary patient material is extremely scarce and accurate animal models are not available. In this short review, we explain why pluripotent stem cell derived islets present an attractive solution to these issues and outline the current progress in stem-cell based modeling of CHI. Stem cell derived islets enable the study of molecular mechanisms of CHI and the discovery of novel antihypoglycemic drugs, while also providing a valuable model to study the biology of variable functional states of beta cells.
Collapse
Affiliation(s)
- Väinö Lithovius
- Stem Cells and Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- *Correspondence: Väinö Lithovius, ; Timo Otonkoski,
| | - Timo Otonkoski
- Stem Cells and Metabolism Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
- *Correspondence: Väinö Lithovius, ; Timo Otonkoski,
| |
Collapse
|
16
|
Özbek MN, Demiral M, Unal E, Karaşin ND, Baran RT, Demirbilek H. A rare and preventable aetiology of neurodevelopmental delay and epilepsy: familial glucocorticoid deficiency. J Pediatr Endocrinol Metab 2021; 34:1463-1468. [PMID: 34271604 DOI: 10.1515/jpem-2021-0150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/20/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Familial glucocorticoid deficiency (FGD) is a rare autosomal recessive disorder characterised by isolated glucocorticoid deficiency. Melanocortin receptor 2 (MC2R) mediates the functions of adrenocorticotropic hormone (ACTH) in the adrenal cortex. MC2R accessory protein (MRAP) is a transmembrane protein involved in the trafficking of MC2R to the cell surface. Mutations in MC2R and MRAP genes cause FGD type 1 and 2. In the present case series, we evaluate the clinical characteristics and long-term follow-up of six cases with FGD due to mutations in MC2R and MRAP. CASE PRESENTATION Data of six cases with FGD (five with mutations in MC2R and one with a mutation in MRAP) who were being followed at our paediatric endocrine centre was evaluated. Diagnosis of FGD was considered in case of elevated ACTH and inappropriately low cortisol level, and exclusion of other aetiologies. The main presenting complaints were hyperpigmentation and hypoglycaemic convulsion in all cases. During a follow-up period of 26-115 months, one patient with homozygous 560delT mutation in MC2R, one female with G226R mutation in MC2R and one female with IVS3ds+1delG mutation in MRAP had a neurodevelopmental delay (NDD), while the other three patients had normal neurodevelopment. CONCLUSIONS FGD patients due to MC2R and MRAP mutations with early diagnosis and compliance to the hydrocortisone therapy had normal neurodevelopment, while delay in diagnosis and poor compliance was associated with severe hypoglycaemic convulsions and subsequent complications NDD.
Collapse
Affiliation(s)
- Mehmet Nuri Özbek
- Department of Paediatric Endocrinology, Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Meliha Demiral
- Department of Paediatric Endocrinology, Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Edip Unal
- Department of Paediatric Endocrinology, Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Nezahat Doğan Karaşin
- Department of Paediatrics, Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Rıza Taner Baran
- Department of Paediatric Endocrinology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Huseyin Demirbilek
- Department of Paediatric Endocrinology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| |
Collapse
|
17
|
Loh WJ, Dacay LM, Tan CSH, Ang SF, Yap F, Lim SC, Khoo J. Glucokinase activating mutation causing hypoglycaemia diagnosed late in adult who fasts for Ramadhan. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210043. [PMID: 34184638 PMCID: PMC8240715 DOI: 10.1530/edm-21-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/25/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Activating mutation of glucokinase gene (GCK) causes resetting of insulin inhibition at a lower glucose threshold causing hyperinsulinaemic hypoglycaemia (GCK-HH). This is the first reported case who tolerated years of regular fasting during Ramadhan, presenting only with seizure and syncope now. We describe a case with GCK gene variant p.T65I diagnosed in a 51-year-old woman with hypoglycaemia unawareness even at glucose level of 1.6 mmol/L. Insulin and C-peptide levels during hypoglycaemia were suggestive of hyperinsulinism, but at a day after intravenous glucagon, hypoglycaemia occurred with low insulin and C-peptide levels, pointing against insulinoma as the underlying aetiology. Imaging studies of the pancreas and calcium arterial stimulation venous sampling were unremarkable. A review of old medical records revealed asymptomatic hypoglycaemia years ago. Genetic testing confirmed activating mutation of GCK. Hypoglycaemia was successfully controlled with a somatostatin analogue. This case highlights the importance of consideration of genetic causes of hypoglycaemia in adulthood, especially when imaging is uninformative. LEARNING POINTS Consider genetic causes of endogenous hyperinsulinism hypoglycaemia in adulthood, especially when imaging is uninformative. Late presentation of activating mutation of GCK can occur because of hypoglycaemia unawareness. Long-acting somatostatin analogue may be useful for the treatment of activating mutation of GCK causing hypoglycaemia. Depending on the glucose level when the blood was taken, and the threshold of glucose-stimulated insulin release (GSIR), the serum insulin and C-peptide levels may be raised (hyperinsulinaemic) or low (hypoinsulinaemic) in patients with activating mutation of GCK. Glucagon may be useful to hasten the process of unmasking the low insulin level during hypoglycaemia below the GSIR level of which insulin released is suppressed.
Collapse
Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Lily Mae Dacay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Clara Si Hua Tan
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Su Fen Ang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Fabian Yap
- Department of Paediatric Endocrinology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| |
Collapse
|
18
|
Roeper M, Salimi Dafsari R, Hoermann H, Hoehn T, Kummer S, Meissner T. Clinical management and knowledge of neonatal hypoglycaemia in Germany: A national survey of midwives and nurses. J Paediatr Child Health 2021; 57:854-859. [PMID: 33682210 DOI: 10.1111/jpc.15337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/20/2020] [Accepted: 12/23/2020] [Indexed: 11/28/2022]
Abstract
AIM Despite being a common metabolic condition, the detection and care of neonatal hypoglycaemia in Germany largely depends on the infant's health-care provider, rather than a national protocol. Therefore, this study aimed to evaluate midwives' and nurses' knowledge and management of neonatal hypoglycaemia and to determine the need for national guidelines. METHODS An anonymous online survey was developed and completed by 127 perinatal nurses and midwives. Descriptive statistics, Mann-Whitney-U, χ2 and Fisher's exact tests were used to summarise and analyse the results. RESULTS In total, 82% of respondents indicated using guidelines but routine blood glucose screening for neonates at risk for hypoglycaemia was rarely reported (44%). A blood glucose concentration of 2.5 mmol/L (45 mg/dL) was considered the treatment threshold by 52% of the respondents. However, the responses to clinical scenarios showed distinct differences regarding the management of neonatal hypoglycaemia. Finally, 49% of respondents reported insufficient knowledge regarding neonatal hypoglycaemia and 77% indicated that they would advocate the implication of enhanced national guidelines. CONCLUSIONS There is considerable variation in knowledge about the prevention, screening and management of neonatal hypoglycaemia among nurses and midwives in Germany. Enhanced guidelines and education of health-care professionals are urgently needed to provide the best possible care to all hypoglycaemic newborns.
Collapse
Affiliation(s)
- Marcia Roeper
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Duesseldorf, Germany
| | - Roschan Salimi Dafsari
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Duesseldorf, Germany
| | - Henrike Hoermann
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Duesseldorf, Germany
| | - Thomas Hoehn
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Duesseldorf, Germany
| | - Sebastian Kummer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Duesseldorf, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital Duesseldorf, Duesseldorf, Germany
| |
Collapse
|
19
|
Musthaffa Y, Papadimos ER, Fairchild J, Titmuss A, Corpus S, Huynh T, Conwell LS. Challenges of managing congenital hyperinsulinism in remote Aboriginal Australian communities. J Paediatr Child Health 2021; 57:727-731. [PMID: 32808382 DOI: 10.1111/jpc.14984] [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: 02/16/2020] [Revised: 04/14/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Yassmin Musthaffa
- Department of Endocrinology and Diabetes, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Department of Paediatrics, Logan Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Emily R Papadimos
- Department of Endocrinology and Diabetes, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jan Fairchild
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Angela Titmuss
- Division of Women, Children and Youth, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Sumaria Corpus
- Danila Dilba Health Service, Darwin, Northern Territory, Australia
| | - Tony Huynh
- Department of Endocrinology and Diabetes, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Department of Chemical Pathology, Mater Pathology, Brisbane, Queensland, Australia
| | - Louise S Conwell
- Department of Endocrinology and Diabetes, Queensland Children's Hospital, Brisbane, Queensland, Australia.,School of Clinical Medicine, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| |
Collapse
|
20
|
Laimon W, Aboelenin HM, El Tantawi NT. Clinical characteristics, outcome, and predictors of neurological sequelae of persistent congenital hyperinsulinism: A single tertiary center experience. Pediatr Diabetes 2021; 22:388-399. [PMID: 33528087 DOI: 10.1111/pedi.13186] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/09/2020] [Accepted: 12/29/2020] [Indexed: 11/29/2022] Open
Abstract
AIM Congenital hyperinsulinism (CHI) is a heterogeneous disease with variable genetic etiology, histopathology, and clinical phenotype. This study aims to describe the clinical characteristics of persistent CHI and evaluate long-term neurological outcome and its risk factors in a cohort of Egyptian children. METHODS Clinical, genetic, and biochemical data of 42 patients with CHI were collected. Patients were invited for neurological assessment, electroencephalogram, and magnetic resonance imaging of the brain. RESULTS ABCC8 mutation was found in (61%) of cases who underwent genetic testing (17/28). Five cases with homozygous biparental ABCC8 mutation responded to combined diazoxide and octreotide without needing surgery. Seven out of twenty-one patients who had pancreatectomy (33%) developed diabetes after a median period of 4.8 (range:1-10) years following surgery. Fifty-five percent of our patients had neurodevelopmental impairment at follow-up. Logistic regression analysis has shown that delayed referral to tertiary centre for more than 8 days, delayed diagnosis of CHI for more than 14 days and hospital admission for more than 30 days, are significant predictors of unfavorable neurological sequelae in CHI; (OR = 12.7 [2.56], p = 0.001), (OR = 12.7 [2.9-56], p = 0.001), and (OR = 3.8 [0.14.5], p = 0.043), respectively. CONCLUSIONS ABCC8 mutation was the commonest genetic mutation underlying CHI in this study group. CHI cases with biparental homozygous ABCC8 mutation may show response to combined octreotide and diazoxide therapy. More than half of our patients had neurodevelopmental impairment at follow-up. Delayed referral to expert centre, delayed diagnosis and longer hospital stay are significant predictors of neurological disability in CHI cases.
Collapse
Affiliation(s)
- Wafaa Laimon
- Pediatric Endocrinology and Diabetes Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Hadil Mohamed Aboelenin
- Pediatric Endocrinology and Diabetes Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
| | - Noha T El Tantawi
- Pediatric Neurology Unit, Department of Pediatrics, Mansoura Faculty of Medicine, Mansoura University, Mansoura University Children's Hospital, Mansoura, Egypt
| |
Collapse
|
21
|
Amaratunga SA, Hussein Tayeb T, Rozenkova K, Kucerova P, Pruhova S, Lebl J. Congenital Hyperinsulinism Caused by Novel Homozygous KATP Channel Gene Variants May Be Linked to Unexplained Neonatal Deaths among Kurdish Consanguineous Families. Horm Res Paediatr 2021; 93:58-65. [PMID: 32203961 DOI: 10.1159/000506476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 02/01/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Neonatal hypoglycemia due to congenital hyperinsulinism (CHI) is a potentially life-threatening condition. Biallelic pathogenic variants in KATP channel subunit genes (ABCC8, KCNJ11), causing severe forms of CHI, are more prevalent in regions with a significant rate of consanguinity and may lead to unexplained neonatal deaths. We hypothesized that KATP channel gene variants are the cause of CHI in three unrelated children from consanguineous Kurdish families with histories of four unexplained neonatal deaths with convulsions. CASES (1) A girl presented on the 6th day of life with recurrent hypoglycemic convulsions (blood glucose 2.05 mmol/L, insulin 58 mIU/L, C-peptide 2,242 pmol/L). (2) A girl with severe developmental delay was diagnosed with CHI at 3 years of age (blood glucose 2.78 mmol/L, insulin 8.1 mIU/L, C-peptide 761 pmol/L) despite a history of recurrent hypoglycemia since neonatal age. (3) A girl presented at 3 weeks of age with convulsions and unconsciousness (blood glucose 2.5 mmol/L, insulin 14.6 mIU/L, C-peptide 523 pmol/L). Coding regions of the ABCC8 and KCNJ11 genes were tested by Sanger sequencing. Potential variants were evaluated using the American College of Medical Genetics standards. Three novel causative homozygous variants were found - p.Trp514Ter in the ABCC8 gene (Pt2), and p.Met1Val (Pt1) and p.Tyr26Ter (Pt3) in the KCNJ11 gene. CONCLUSION CHI caused by KATP channel variants was elucidated in three children, providing a highly probable retrospective diagnosis for their deceased siblings. Future lives can be saved by timely diagnosis of CHI when encountering a neonate with unexplained seizures or other signs of recurrent and/or persistent hypoglycemia.
Collapse
Affiliation(s)
- Shenali Anne Amaratunga
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia,
| | - Tara Hussein Tayeb
- Department of Pediatrics, Sulaymani University, College of Medicine, Sulaymani, Iraq
| | - Klara Rozenkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Petra Kucerova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Stepanka Pruhova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Jan Lebl
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| |
Collapse
|
22
|
Drachmann D, Hoffmann E, Carrigg A, Davis-Yates B, Weaver V, Thornton P, Weinstein DA, Petersen JS, Shah P, Christesen HT. Towards enhanced understanding of idiopathic ketotic hypoglycemia: a literature review and introduction of the patient organization, Ketotic Hypoglycemia International. Orphanet J Rare Dis 2021; 16:173. [PMID: 33849624 PMCID: PMC8045369 DOI: 10.1186/s13023-021-01797-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic Ketotic hypoglycemia (IKH) is a diagnosis of exclusion. Although considered as the most frequent cause of hypoglycemia in childhood, little progress has been made to advance the understanding of IKH since the medical term was coined in 1964. We aimed to review the literature on ketotic hypoglycemia (KH) and introduce a novel patient organization, Ketotic Hypoglycemia International (KHI). RESULTS IKH may be diagnosed after the exclusion of various metabolic and hormonal diseases with KH. Although often mild and self-limiting, more severe and long-lasting IKH occurs. We therefore divide IKH in physiological KH and pathological KH, the latter defined as recurrent symptomatic, or occasionally symptomatic, episodes with beta-hydroxybutyrate ≥ 1.0 mmol/L and blood glucose < 70 mg/dL (3.9 mol/L), in the absence of prolonged fasting, acute infections and chronic diseases known to cause KH. Pathological KH may represent undiscovered diseases, e.g. glycogen storage disease IXa, Silver-Russel syndrome, and ketone transporter defects, or suggested novel disease entities identified by exome sequencing. The management of KH aims to prevent hypoglycemia, fatty acid oxidation and protein deficiency by supplying adequate amounts of carbohydrates and protein, including nutritional therapy, uncooked cornstarch, and sometimes continuous tube feeding by night. Still, intravenous dextrose may be needed in acute KH episodes. Failure to acknowledge that IKH can be more than normal variation may lead to under-treatment. KHI is a non-profit, patient-centric, global organization established in 2020. The organization was created by adult IKH patients, patient family members, and volunteers. The mission of KHI is to enhance the understanding of IKH while advocating for patients, their families and the continued research into KH. CONCLUSION IKH is a heterogeneous disorder including physiological KH and pathological KH. IKH may represent missed diagnoses or novel disease entities, but shares common management principles to prevent fatty acid oxygenation. KHI, a novel patient organization, aims to enhance the understanding of IKH by supporting IKH families and research into IKH.
Collapse
Affiliation(s)
| | - Erica Hoffmann
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | - Austin Carrigg
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | - Beccie Davis-Yates
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark.,School of Social Science, Nottingham Institute of Education, Nottingham, UK
| | - Valerie Weaver
- Ketotic Hypoglycemia International (KHI), Skanderborg, Denmark
| | | | - David A Weinstein
- Glycogen Storage Disease Program, University of Connecticut, Farmington, CT, USA
| | | | - Pratik Shah
- Endocrinology Department, The Royal London Children's Hospital, Barts Health NHS Trust and Queen Mary University London, London, UK
| | - Henrik Thybo Christesen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Hans Christian Andersen Children's Hospital and Steno Diabetes Centre Odense, Odense University Hospital, JB Windsloews Vej 4, 5000, Odense C, Denmark.
| |
Collapse
|
23
|
Männistö JME, Jääskeläinen J, Otonkoski T, Huopio H. Long-Term Outcome and Treatment in Persistent and Transient Congenital Hyperinsulinism: A Finnish Population-Based Study. J Clin Endocrinol Metab 2021; 106:e1542-e1551. [PMID: 33475139 PMCID: PMC7993590 DOI: 10.1210/clinem/dgab024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 12/29/2022]
Abstract
CONTEXT The management of congenital hyperinsulinism (CHI) has improved. OBJECTIVE To examine the treatment and long-term outcome of Finnish patients with persistent and transient CHI (P-CHI and T-CHI). DESIGN A population-based retrospective study of CHI patients treated from 1972 to 2015. PATIENTS 106 patients with P-CHI and 132 patients with T-CHI (in total, 42 diagnosed before and 196 after year 2000) with median follow-up durations of 12.5 and 6.2 years, respectively. MAIN OUTCOME MEASURES Recovery, diabetes, pancreatic exocrine dysfunction, neurodevelopment. RESULTS The overall incidence of CHI (n = 238) was 1:11 300 live births (1972-2015). From 2000 to 2015, the incidence of P-CHI (n = 69) was 1:13 500 and of T-CHI (n = 127) 1:7400 live births. In the 21st century P-CHI group, hyperinsulinemic medication was initiated and normoglycemia achieved faster relative to earlier. Of the 74 medically treated P-CHI patients, 68% had discontinued medication. Thirteen (12%) P-CHI patients had partial pancreatic resection and 19 (18%) underwent near-total pancreatectomy. Of these, 0% and 84% developed diabetes and 23% and 58% had clinical pancreatic exocrine dysfunction, respectively. Mild neurological difficulties (21% vs 16%, respectively) and intellectual disability (9% vs 5%, respectively) were as common in the P-CHI and T-CHI groups. However, the 21st century P-CHI patients had significantly more frequent normal neurodevelopment and significantly more infrequent diabetes and pancreatic exocrine dysfunction compared with those diagnosed earlier. CONCLUSIONS Our results demonstrated improved treatment and long-term outcome in the 21st century P-CHI patients relative to earlier.
Collapse
Affiliation(s)
- Jonna M E Männistö
- Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
- Correspondence: Jonna Männistö, MD, Department of Pediatrics, Kuopio University Hospital, P.O. Box 100, FI-70029 KYS, Kuopio, Finland.
| | - Jarmo Jääskeläinen
- Department of Pediatrics, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Timo Otonkoski
- Children’s Hospital and Stem Cells and Metabolism Research Program, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Hanna Huopio
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| |
Collapse
|
24
|
Mouron-Hryciuk J, Stoppa-Vaucher S, Busiah K, Bouthors T, Antoniou MC, Jacot E, Brusgaard K, Christesen HT, Hussain K, Dwyer A, Roth-Kleiner M, Hauschild M. Congenital hyperinsulinism: 2 case reports with different rare variants in ABCC8. Ann Pediatr Endocrinol Metab 2021; 26:60-65. [PMID: 32871644 PMCID: PMC8026340 DOI: 10.6065/apem.2040042.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 05/19/2020] [Indexed: 11/20/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a rare glucose metabolism disorder characterized by unregulated secretion of insulin that leads to hyperinsulinemic hypoglycemia (HH). Most cases are caused by mutations in the KATP-channel genes ABCC8 and KCNJ11. We report 2 patients that experienced severe HH from the first day of life. Patient 1 developed midgut volvulus after initiating diazoxide and required intestinal resection. He was subsequently managed with a high-dose octreotide and glucose-enriched diet. Consistent with diffuse type CHI by 18F-dihydroxyphenylalanine positron emission tomography-computed tomography, genetic testing revealed a homozygous ABCC8 variant, c.1801G>A, p.(Val601Ile). The rare variant was previously reported to be diazoxide-responsive, and the patient responded well to diazoxide monotherapy, with clinical remission at 2 years of age. Patient 2 responded to diazoxide with spontaneous clinical remission at 15 months of age. However, an oral glucose tolerance test at 7 years of age revealed hyperinsulinism. Genetic testing revealed that the proband and several seemingly healthy family members harbored a novel, heterozygous ABCC8 variant, c.1780T>C, p.(Ser594Pro). Genetic findings identified previously unrecognized HH in the proband's mother. The proband's uncle had been diagnosed with monogenic ABCC8-diabetes and was successfully transitioned from insulin to glibenclamide therapy. We report findings of intestinal malrotation and volvulus occurring 2 days after initiation of diazoxide treatment. We also report a novel, heterozygous ABCC8 variant in a family that exhibited cases of CHI in infancy and HH and monogenic diabetes in adult members. The cases demonstrate the importance and clinical utility of genetic analyses for informing and guiding treatment and care.
Collapse
Affiliation(s)
- Julie Mouron-Hryciuk
- Pediatric Endocrinology and Diabetology Unit, Ser vice of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Sophie Stoppa-Vaucher
- Pediatric Endocrinology and Diabetology Unit, Ser vice of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland,Department of Pediatrics, Hôpitaux Neuchâtelois, Neuchâtel, Switzerland
| | - Kanetee Busiah
- Pediatric Endocrinology and Diabetology Unit, Ser vice of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thérèse Bouthors
- Pediatric Endocrinology and Diabetology Unit, Ser vice of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Maria Christina Antoniou
- Pediatric Endocrinology and Diabetology Unit, Ser vice of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Klaus Brusgaard
- Departement of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | | | - Khalid Hussain
- D e velopmental Endocr inology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, London, UK
| | - Andrew Dwyer
- Boston College, William F. Connell School of Nursing, Chestnut Hill, MA, USA
| | - Matthias Roth-Kleiner
- Service of Neonatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Hauschild
- Pediatric Endocrinology and Diabetology Unit, Ser vice of Pediatrics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland,Address for correspondence: Michael Hauschild Pediatric Endocrinology and Diabetology Unit, Service of Pediatrics, Lausanne University Hospital and University of Lausanne, Chemin de Montétan 16 1004 Lausanne, Switzerland
| |
Collapse
|
25
|
Alhaidan Y, Christesen HT, Lundberg E, Balwi MAA, Brusgaard K. CRISPR/Cas9 ADCY7 Knockout Stimulates the Insulin Secretion Pathway Leading to Excessive Insulin Secretion. Front Endocrinol (Lausanne) 2021; 12:657873. [PMID: 34177802 PMCID: PMC8231291 DOI: 10.3389/fendo.2021.657873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/18/2021] [Indexed: 11/15/2022] Open
Abstract
AIM Despite the enormous efforts to understand Congenital hyperinsulinism (CHI), up to 50% of the patients are genetically unexplained. We aimed to functionally characterize a novel candidate gene in CHI. PATIENT A 4-month-old boy presented severe hyperinsulinemic hypoglycemia. A routine CHI genetic panel was negative. METHODS A trio-based whole-exome sequencing (WES) was performed. Gene knockout in the RIN-m cell line was established by CRISPR/Cas9. Gene expression was performed using real-time PCR. RESULTS Hyperinsulinemic hypoglycemia with diffuse beta-cell involvement was demonstrated in the patient, who was diazoxide-responsive. By WES, compound heterozygous variants were identified in the adenylyl cyclase 7, ADCY7 gene p.(Asp439Glu) and p.(Gly1045Arg). ADCY7 is calcium-sensitive, expressed in beta-cells and converts ATP to cAMP. The variants located in the cytoplasmic domains C1 and C2 in a highly conserved and functional amino acid region. RIN-m(-/-Adcy7) cells showed a significant increase in insulin secretion reaching 54% at low, and 49% at high glucose concentrations, compared to wild-type. In genetic expression analysis Adcy7 loss of function led to a 34.1-fold to 362.8-fold increase in mRNA levels of the insulin regulator genes Ins1 and Ins2 (p ≤ 0.0002), as well as increased glucose uptake and sensing indicated by higher mRNA levels of Scl2a2 and Gck via upregulation of Pdx1, and Foxa2 leading to the activation of the glucose stimulated-insulin secretion (GSIS) pathway. CONCLUSION This study identified a novel candidate gene, ADCY7, to cause CHI via activation of the GSIS pathway.
Collapse
Affiliation(s)
- Yazeid Alhaidan
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Medical Genomics Research, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- *Correspondence: Yazeid Alhaidan,
| | - Henrik Thybo Christesen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
- Odense Pancreas Center, Odense, Denmark
| | - Elena Lundberg
- Institute of Clinical Science, Pediatrics, Umea University, Umeå, Sweden
| | - Mohammed A. Al Balwi
- Department of Medical Genomics Research, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, NGHA, Riyadh, Saudi Arabia
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Near East University, Nicosia, Cyprus
| |
Collapse
|
26
|
Bjarnesen AP, Dahlin P, Globa E, Petersen H, Brusgaard K, Rasmussen L, Melikian M, Detlefsen S, Christesen HT, Mortensen MB. Intraoperative ultrasound imaging in the surgical treatment of congenital hyperinsulinism: prospective, blinded study. BJS Open 2020; 5:5973900. [PMID: 33688939 PMCID: PMC7944853 DOI: 10.1093/bjsopen/zraa008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/04/2020] [Indexed: 11/24/2022] Open
Abstract
Background In congenital hyperinsulinism (CHI), preoperative prediction of the histological subtype (focal, diffuse, or atypical) relies on genetics and 6-[18F]fluoro-l-3,4-dihydroxyphenylalanine (18F-DOPA) PET–CT. The scan also guides the localization of a potential focal lesion along with perioperative frozen sections. Intraoperative decision-making is still challenging. This study aimed to describe the characteristics and potential clinical impact of intraoperative ultrasound imaging (IOUS) during CHI surgery. Methods This was a prospective, observational study undertaken at an expert centre over a 2-year interval. IOUS was performed blinded to preoperative diagnostic test results (genetics and 18F-DOPA PET–CT), followed by unblinding and continued IOUS during pancreatic resection. Characteristics and clinical impact were assessed using predefined criteria. Results Eighteen consecutive, surgically treated patients with CHI, with a median age of 5.5 months, were included (focal 12, diffuse 3, atypical 3). Focal lesions presented as predominantly hypoechoic, oval lesions with demarcated or blurred margins. Patients with diffuse and atypical disease had varying echogenicity featuring stranding and non-shadowing hyperechoic foci in three of six, whereas these characteristics were absent from those with focal lesions. The blinded IOUS-based subclassification was correct in 17 of 18 patients; one diffuse lesion was misclassified as focal. IOUS had an impact on the surgical approach in most patients with focal lesions (9 of 12), and in those with diffuse (2 of 3) and atypical (2 of 3) disease when the resection site was close to the bile or pancreatic duct. Conclusion Uniform IOUS characteristics made all focal lesions identifiable. IOUS had a clinical impact in 13 of 18 patients by being a useful real-time supplementary modality in terms of localizing focal lesions, reducing the need for frozen sections, and preserving healthy tissue and delicate structures.
Collapse
Affiliation(s)
- A P Bjarnesen
- Upper Gastrointestinal and Hepato-Pancreato-Biliary Section, Department of Surgery, Odense University Hospital, Odense, Denmark
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
| | - P Dahlin
- Upper Gastrointestinal and Hepato-Pancreato-Biliary Section, Department of Surgery, Odense University Hospital, Odense, Denmark
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
| | - E Globa
- Ukrainian Research Centre of Endocrine Surgery, Endocrine Organs and Tissue Transplantation, Paediatric Endocrinology Department, Ministry of Health of Ukraine, Kiev, Ukraine
| | - H Petersen
- PET and Cyclotron Unit, Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - K Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - L Rasmussen
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
- Paediatric Surgery Section, Department of Surgery, Odense University Hospital, Odense, Denmark
| | - M Melikian
- Endocrine Research Centre, Department of Paediatric Endocrinology, Moscow, Russia
| | - S Detlefsen
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - H T Christesen
- Odense Pancreas Centre, OPAC, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
| | - M B Mortensen
- Correspondence to: Department of Surgery, Odense University Hospital, J. B. Winsløvs Vej 4, 5000 Odense C, Denmark (e-mail: )
| |
Collapse
|
27
|
Joyce CM, Houghton JA, O’Halloran DJ, O’Shea PM, O’Connell SM. Inheritance of a paternal ABCC8 variant and maternal loss of heterozygosity at 11p15 retrospectively unmasks the etiology in a case of Congenital hyperinsulinism. Clin Case Rep 2020; 8:1217-1222. [PMID: 32695361 PMCID: PMC7364106 DOI: 10.1002/ccr3.2885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/08/2020] [Accepted: 04/02/2020] [Indexed: 11/29/2022] Open
Abstract
Advances in genomics and 18F-DOPA PET-CT imaging have transformed the management of infants with Congenital Hyperinsulinism. Preoperative diagnosis of focal hyperinsulinism permits limited pancreatectomy with improved clinical outcomes while knowledge of the molecular etiology informs genetic counseling and provides a more accurate recurrence risk to families.
Collapse
Affiliation(s)
- Caroline M. Joyce
- Department of Clinical BiochemistryCork University HospitalCorkIreland
| | - Jayne A. Houghton
- Exeter Genomics LaboratoryRoyal Devon and Exeter NHS Foundation TrustExeterUK
| | | | - Paula M. O’Shea
- Department of Clinical BiochemistryUniversity College HospitalGalwayIreland
| | - Susan M. O’Connell
- Department of Paediatrics and Child HealthCork University HospitalCorkIreland
| |
Collapse
|
28
|
Pipatpolkai T, Usher S, Stansfeld PJ, Ashcroft FM. New insights into K ATP channel gene mutations and neonatal diabetes mellitus. Nat Rev Endocrinol 2020; 16:378-393. [PMID: 32376986 DOI: 10.1038/s41574-020-0351-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/17/2020] [Indexed: 12/12/2022]
Abstract
The ATP-sensitive potassium channel (KATP channel) couples blood levels of glucose to insulin secretion from pancreatic β-cells. KATP channel closure triggers a cascade of events that results in insulin release. Metabolically generated changes in the intracellular concentrations of adenosine nucleotides are integral to this regulation, with ATP and ADP closing the channel and MgATP and MgADP increasing channel activity. Activating mutations in the genes encoding either of the two types of KATP channel subunit (Kir6.2 and SUR1) result in neonatal diabetes mellitus, whereas loss-of-function mutations cause hyperinsulinaemic hypoglycaemia of infancy. Sulfonylurea and glinide drugs, which bind to SUR1, close the channel through a pathway independent of ATP and are now the primary therapy for neonatal diabetes mellitus caused by mutations in the genes encoding KATP channel subunits. Insight into the molecular details of drug and nucleotide regulation of channel activity has been illuminated by cryo-electron microscopy structures that reveal the atomic-level organization of the KATP channel complex. Here we review how these structures aid our understanding of how the various mutations in the genes encoding Kir6.2 (KCNJ11) and SUR1 (ABCC8) lead to a reduction in ATP inhibition and thereby neonatal diabetes mellitus. We also provide an update on known mutations and sulfonylurea therapy in neonatal diabetes mellitus.
Collapse
Affiliation(s)
- Tanadet Pipatpolkai
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
- Department of Biochemistry, University of Oxford, Oxford, UK
| | - Samuel Usher
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - Phillip J Stansfeld
- Department of Biochemistry, University of Oxford, Oxford, UK
- School of Life Sciences, University of Warwick, Coventry, UK
- Department of Chemistry, University of Warwick, Coventry, UK
| | - Frances M Ashcroft
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK.
| |
Collapse
|
29
|
Rasmussen AG, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Rasmussen AH, Mortensen MB, Christesen HT. The difficult management of persistent, non-focal congenital hyperinsulinism: A retrospective review from a single, tertiary center. Pediatr Diabetes 2020; 21:441-455. [PMID: 31997554 DOI: 10.1111/pedi.12989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 11/14/2019] [Accepted: 01/13/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Congenital hyperinsulinism (CHI) is a rare, heterogeneous disease with transient or persistent hypoglycemia. Histologically, focal, diffuse, and atypical forms of CHI exist, and at least 11 disease-causing genes have been identified. METHODS We retrospectively evaluated the treatment and outcome of a cohort of 40 patients with non-focal, persistent CHI admitted to the International Hyperinsulinism Center, Denmark, from January 2000 to May 2017. RESULTS Twenty-two patients (55%) could not be managed with medical monotherapy (diazoxide or octreotide) and six (15%) patients developed severe potential side effects to medication. Surgery was performed in 17 (43%) patients with resection of 66% to 98% of the pancreas. Surgically treated patients had more frequently KATP -channel gene mutations (surgical treatment 12/17 vs conservative treatment 6/23, P = .013), highly severe disease (15/17 vs 13/23, P = .025) and clinical onset <30 days of age (15/17 vs 10/23, P = .004). At last follow-up at median 5.3 (range: 0.3-31.3) years of age, 31/40 (78%) patients still received medical treatment, including 12/17 (71%) after surgery. One patient developed diabetes after a 98% pancreatic resection. Problematic treatment status was seen in 7/40 (18%). Only 8 (20%) had clinical remission (three spontaneous, five after pancreatic surgery). Neurodevelopmental impairment (n = 12, 30%) was marginally associated with disease severity (P = .059). CONCLUSIONS Persistent, non-focal CHI remains difficult to manage. Neurological impairment in 30% suggests a frequent failure of prompt and adequate treatment. A high rate of problematic treatment status at follow-up demonstrates an urgent need for new medical treatment modalities.
Collapse
Affiliation(s)
- Amalie G Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Melikian
- Department of Pediatric Endocrinology, Endrocrine Research Center, Moscow, Russia
| | - Evgenia Globa
- Department of Pediatric Endocrinology, Ukrainian Research Center of Endocrine Surgery, Kyiv, Ukraine
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Annett H Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Michael B Mortensen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik T Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| |
Collapse
|
30
|
De Franco E, Saint-Martin C, Brusgaard K, Knight Johnson AE, Aguilar-Bryan L, Bowman P, Arnoux JB, Larsen AR, Sanyoura M, Greeley SAW, Calzada-León R, Harman B, Houghton JAL, Nishimura-Meguro E, Laver TW, Ellard S, Del Gaudio D, Christesen HT, Bellanné-Chantelot C, Flanagan SE. Update of variants identified in the pancreatic β-cell K ATP channel genes KCNJ11 and ABCC8 in individuals with congenital hyperinsulinism and diabetes. Hum Mutat 2020; 41:884-905. [PMID: 32027066 PMCID: PMC7187370 DOI: 10.1002/humu.23995] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 01/08/2020] [Accepted: 02/04/2020] [Indexed: 01/03/2023]
Abstract
The most common genetic cause of neonatal diabetes and hyperinsulinism is pathogenic variants in ABCC8 and KCNJ11. These genes encode the subunits of the β-cell ATP-sensitive potassium channel, a key component of the glucose-stimulated insulin secretion pathway. Mutations in the two genes cause dysregulated insulin secretion; inactivating mutations cause an oversecretion of insulin, leading to congenital hyperinsulinism, whereas activating mutations cause the opposing phenotype, diabetes. This review focuses on variants identified in ABCC8 and KCNJ11, the phenotypic spectrum and the treatment implications for individuals with pathogenic variants.
Collapse
Affiliation(s)
- Elisa De Franco
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Cécile Saint-Martin
- Department of Genetics, Pitié-Salpêtrière Hospital, AP-HP, Sorbonne University, Paris, France
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Amy E Knight Johnson
- Department of Human Genetics, University of Chicago Genetic Services Laboratory, The University of Chicago, Chicago, Illinois
| | | | - Pamela Bowman
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Jean-Baptiste Arnoux
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants Malades Hospital, Paris, France
| | - Annette Rønholt Larsen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - May Sanyoura
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Kovler Diabetes Center, University of Chicago, Chicago, Illinois
| | - Siri Atma W Greeley
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Kovler Diabetes Center, University of Chicago, Chicago, Illinois
| | - Raúl Calzada-León
- Pediatric Endocrinology, Endocrine Service, National Institute for Pediatrics, Mexico City, Mexico
| | - Bradley Harman
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Jayne A L Houghton
- Department of Molecular Genetics, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Elisa Nishimura-Meguro
- Department of Pediatric Endocrinology, Children's Hospital, National Medical Center XXI Century, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Thomas W Laver
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.,Department of Molecular Genetics, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Daniela Del Gaudio
- Department of Human Genetics, University of Chicago Genetic Services Laboratory, The University of Chicago, Chicago, Illinois
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Odense Pancreas Center, Odense University Hospital, Odense, Denmark
| | | | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| |
Collapse
|
31
|
Roeper M, Salimi Dafsari R, Hoermann H, Mayatepek E, Kummer S, Meissner T. Risk Factors for Adverse Neurodevelopment in Transient or Persistent Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2020; 11:580642. [PMID: 33424766 PMCID: PMC7793856 DOI: 10.3389/fendo.2020.580642] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/29/2020] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Aim was to identify hypotheses why adverse neurodevelopment still occurs in children with transient or persistent hyperinsulinism despite improvements in long-term treatment options during the last decades. MATERIAL AND METHODS A retrospective review of 87 children with transient (n=37) or persistent congenital hyperinsulinism (CHI) (n=50) was conducted at the University Children's Hospital Duesseldorf, Germany. Possible risk factors for neurodevelopmental sequelae due to hypoglycemia were analyzed with a focus on the first days after onset of disease. RESULTS Median age at follow-up was 7 years (IQR 8). Adverse neurodevelopmental outcome was seen in 34.5% (n=30) of all CHI patients. Fifteen had mildly abnormal neurodevelopment and 15 had a severe hypoglycemic brain injury. In univariate analysis, mildly abnormal neurodevelopment was associated with the diagnosis of persistent CHI (odds ratio (OR) 8.3; p=0.004) and higher birth weight (mean difference 1049 g; p<0.001). Severe hypoglycemic brain injury was associated with the diagnosis of persistent CHI (OR 5.1; p=0.013), being born abroad (OR 18.3; p<0.001) or in a lower-level maternity hospital (OR 4.8; p=0.039), and of note history of hypoglycemic seizures (OR 13.0; p=<0.001), and a delay between first symptoms of hypoglycemia and first blood glucose measurement/initiation of treatment (OR 10.7; p<0.001). Children with severe hypoglycemic brain injury had lower recorded blood glucose (mean difference -8.34 mg/dl; p=0.022) and higher birth weight than children with normal development (mean difference 829 g; p=0.012). In multivariate binary logistic regression models, lowest blood glucose <20 mg/dl (OR 134.3; p=0.004), a delay between initial symptoms and first blood glucose measurement/initiation of treatment (OR 71.7; p=0.017) and hypoglycemic seizures (OR 12.9; p=0.008) were positively correlated with severe brain injury. Analysis showed that the odds for brain injury decreased by 15% (OR 0.85; p=0.035) if the blood glucose increased by one unit. CONCLUSION While some risk factors for adverse outcome in CHI are not influenceable, others like lowest recorded blood glucose values <20 mg/dl, hypoglycemic seizures, and insufficiently-or even untreated hypoglycemia can be avoided. Future guidelines for management of neonatal hypoglycemia should address this by ensuring early identification and immediate treatment with appropriate escalation steps.
Collapse
|
32
|
Xu ZR, Zhu XY, Lu W, Sun WH, Cheng RQ, Ni JW, Xi L, Hussain K, Luo FH, Zhang MY. Altered Serum Amino Acid and Acylcarnitine Profiles in Hyperinsulinemic Hypoglycemia and Ketotic Hypoglycemia. Front Endocrinol (Lausanne) 2020; 11:577373. [PMID: 33133020 PMCID: PMC7579424 DOI: 10.3389/fendo.2020.577373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/22/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In addition to inborn metabolic disorders, altered metabolic profiles were reported to be associated with the risk and prognosis of some non-metabolic diseases, while as a rare metabolic disease, the overall secondary metabolic spectrum in congenital hyperinsulinemic hypoglycemia (HH) is largely undetermined. Therefore, we investigated metabolic profiles in HH patients and used ketotic hypoglycemia (KH) patients as a control cohort to unveil their distinct metabolic features. METHODS A total of 97 hypoglycemia children, including 74 with hyperinsulinemic hypoglycemia and 23 with ketotic hypoglycemia, and 170 euglycemia control subjects were studied retrospectively. Clinical and biochemical data were collected. The normoglycemic spectra of amino acids and acylcarnitines were determined by liquid chromatography tandem mass spectrometry. The serum insulin and fatty acid concentrations during standardized fasting tests in hypoglycemia patients were also collected. Receiver operating characteristic curve analysis was performed to screen potential biomarkers. RESULTS Among the normoglycemic spectra of amino acids, blood valine (p < 0.001), arginine (p < 0.001), threonine (p = 0.001), glutamate (p = 0.002), methionine (p = 0.005), ornithine (p = 0.008), leucine (p = 0.014), alanine (p = 0.017), proline (p = 0.031), citrulline (p = 0.042), aspartate (p = 0.046), and glycine (p = 0.048) levels differed significantly among the three groups. Significantly decreased levels of long- (C14:1, p < 0.001; C18, p < 0.001), medium- (C8, p < 0.001; C10, p < 0.001; C10:1, p < 0.001), and short-chain (C4-OH, p < 0.001; C5OH, p < 0.001) acylcarnitines were found in the hyperinsulinemic hypoglycemia group. Hyperinsulinemic hypoglycemia children with focal lesions and diffuse lesions had similar amino acid and acylcarnitine spectra. C10:1 < 0.09 μmol/L, threonine > 35 μmol/L, and threonine/C10:1 > 440 showed sensitivities of 81.1, 66.2, and 81.1% and specificities of 72.7, 78.3, and 81.8%, respectively, in distinguishing HH from KH. CONCLUSIONS We found significantly different altered serum amino acid and acylcarnitine profiles at normoglycemia, especially decreased C10:1 and increased threonine levels, between HH and KH children, which may reflect the insulin ketogenesis inhibition effect in HH patients; however, the detailed mechanisms and physiological roles remain to be studied in the future.
Collapse
Affiliation(s)
- Zhen-Ran Xu
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Xiao-Yi Zhu
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Wei Lu
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Wei-Hua Sun
- Pediatric Research Institute, Children's Hospital of Fudan University, Shanghai, China
| | - Ruo-Qian Cheng
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Jin-Wen Ni
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Li Xi
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Khalid Hussain
- Department of Pediatric Medicine, Weill Cornell Medicine, Division of Endocrinology, Doha, Qatar
| | - Fei-Hong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Miao-Ying Zhang
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
- *Correspondence: Miao-Ying Zhang,
| |
Collapse
|
33
|
Xu A, Cheng J, Sheng H, Wen Z, Lin Y, Zhou Z, Zeng C, Shao Y, Li C, Liu L, Li X. Clinical Management and Gene Mutation Analysis of Children with Congenital Hyperinsulinism in South China. J Clin Res Pediatr Endocrinol 2019; 11:400-409. [PMID: 31208162 PMCID: PMC6878346 DOI: 10.4274/jcrpe.galenos.2019.2019.0046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To explore the clinical presentation and molecular genetic characteristics of a cohort of congenital hyperinsulinism (CHI) patients from southern China and also to explore the most appropriate therapeutic approaches. METHODS We retrospectively reviewed a cohort of 65 children with CHI. Mutational analysis was performed for KCNJ11 and ABCC8 genes. The GLUD1 gene was sequenced in patients with hyperammonaemia. GCK gene sequencing was performed in those patients with no mutation identified in the ABCC8, KCNJ11 or GLUD1 genes. RESULTS ABCC8 mutations were identified in 16 (25%) of the cohort, GLUD1 mutations were identified in five children, and no KCNJ11 or GCK mutations were identified. Moreover, some unique features of ABCC8 gene mutations in southern Chinese CHI patients were found in this study. The most common mutation was a deletion/insertion mutation p.Thr1042GlnfsX75 was found in five unrelated patients, which possibly represents a relatively common mutation in southern China. Five novel ABCC8 mutations were detected. The mutations were p.Phe5SerfsX72, p.Gln273ArgfsX85, p.Leu724del, p.Asp1447Gly and IVS 25-1G>T. Five compound heterozygous mutations of ABCC8 gene were identified in this study, and three of these patients were diazoxide-responsive. Forty patients were diazoxide-responsive, 13 patients were diazoxide-unresponsive and 12 patients received dietary treatment only. A pancreatectomy was performed in 10 patients who were unresponsive to medical treatment. CONCLUSION To the best of our knowledge, this is the first study of CHI in south China. Mutations in ABCC8 are the most common causes of CHI in this cohort. Diazoxide and dietary treatment were effective in most patients. Multicentre studies are necessary to obtain the long-term follow-up characteristics of such patients at a national level.
Collapse
Affiliation(s)
- Aijing Xu
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China,Contributed equally to this work
| | - Jing Cheng
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China,Contributed equally to this work
| | - Huiying Sheng
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Zhe Wen
- Guangzhou Women and Children’s Medical Center, Clinic of Pediatric Surgery, Guangzhou, China
| | - Yunting Lin
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Zhihong Zhou
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Chunhua Zeng
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Yongxian Shao
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Cuiling Li
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Li Liu
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Xiuzhen Li
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China,* Address for Correspondence: Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China Phone: +86020-38076127 E-mail:
| |
Collapse
|
34
|
Thornton P, Truong L, Reynolds C, Hamby T, Nedrelow J. Rate of Serious Adverse Events Associated with Diazoxide Treatment of Patients with Hyperinsulinism. Horm Res Paediatr 2019; 91:25-32. [PMID: 30889588 DOI: 10.1159/000497458] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/03/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Diazoxide is the first line and only Federal Drug Agency approved pharmacological agent for the treatment of hyperinsulinism. Its use has increased over the years to include patients with various genetic forms of hyperinsulinism, perinatal stress hyperinsulinism and infants of diabetic mothers with more babies than ever being exposed to this therapy. METHODS We performed a retrospective analysis of 194 patients with hyperinsulinism in our clinic and looked for those who had experienced serious adverse events (SAE) including pulmonary hypertension and neutropenia. We compared the rates of SAE in the different types of hyperinsulinism. RESULTS Out of 194 patients with hyperinsulinism, 165 (85.1%) were treated with diazoxide. There were 17 SAEs in 16 patients including 8 cases of pulmonary hypertension and 8 of neutropenia. These data show that overall the frequency of SAE associated with diazoxide use is 9.7%, but that those with perinatal stress hyperinsulinism have a much higher rate than those with genetic forms of hyperinsulinism (16.7 vs. 3.6%; p = 0.01). We also found diazoxide is associated with pulmonary hypertension (4.8% of patients treated). Although more patients with perinatal stress hyperinsulinism (7.6%) were affected than genetic hyperinsulinism (1.2%), the difference was not significant (p = 0.088). CONCLUSION The rate of SAEs associated with (not necessarily caused by) diazoxide has been demonstrated. The rate of SAE in newborns with perinatal stress hyperinsulinism is significantly higher than that of otherwise healthy babies with genetic forms of hyperinsulinism, suggesting that caution should be used when prescribing diazoxide to this population. This information should help balance the risk benefit of treatment and provide guidance on screening for these complications in the population of treated patients.
Collapse
Affiliation(s)
- Paul Thornton
- Congenital Hyperinsulinism Center, Division of Endocrinology and Diabetes, Fort Worth, Texas, USA
| | - Lisa Truong
- Congenital Hyperinsulinism Center, Division of Endocrinology and Diabetes, Fort Worth, Texas, USA
| | - Courtney Reynolds
- Congenital Hyperinsulinism Center, Division of Endocrinology and Diabetes, Fort Worth, Texas, USA, .,Research Administration, Fort Worth, Texas, USA,
| | - Tyler Hamby
- Research Administration, Fort Worth, Texas, USA
| | - Jonathan Nedrelow
- Division of Neonatology, Cook Children's Medical Center, Fort Worth, Texas, USA
| |
Collapse
|
35
|
Banerjee I, Salomon‐Estebanez M, Shah P, Nicholson J, Cosgrove KE, Dunne MJ. Therapies and outcomes of congenital hyperinsulinism-induced hypoglycaemia. Diabet Med 2019; 36:9-21. [PMID: 30246418 PMCID: PMC6585719 DOI: 10.1111/dme.13823] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2018] [Indexed: 12/01/2022]
Abstract
Congenital hyperinsulinism is a rare disease, but is the most frequent cause of persistent and severe hypoglycaemia in early childhood. Hypoglycaemia caused by excessive and dysregulated insulin secretion (hyperinsulinism) from disordered pancreatic β cells can often lead to irreversible brain damage with lifelong neurodisability. Although congenital hyperinsulinism has a genetic cause in a significant proportion (40%) of children, often being the result of mutations in the genes encoding the KATP channel (ABCC8 and KCNJ11), not all children have severe and persistent forms of the disease. In approximately half of those without a genetic mutation, hyperinsulinism may resolve, although timescales are unpredictable. From a histopathology perspective, congenital hyperinsulinism is broadly grouped into diffuse and focal forms, with surgical lesionectomy being the preferred choice of treatment in the latter. In contrast, in diffuse congenital hyperinsulinism, medical treatment is the best option if conservative management is safe and effective. In such cases, children receiving treatment with drugs, such as diazoxide and octreotide, should be monitored for side effects and for signs of reduction in disease severity. If hypoglycaemia is not safely managed by medical therapy, subtotal pancreatectomy may be required; however, persistent hypoglycaemia may continue after surgery and diabetes is an inevitable consequence in later life. It is important to recognize the negative cognitive impact of early-life hypoglycaemia which affects half of all children with congenital hyperinsulinism. Treatment options should be individualized to the child/young person with congenital hyperinsulinism, with full discussion regarding efficacy, side effects, outcomes and later life impact.
Collapse
Affiliation(s)
- I. Banerjee
- Department of Paediatric EndocrinologyRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - M. Salomon‐Estebanez
- Department of Paediatric EndocrinologyRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - P. Shah
- Endocrinology DepartmentGreat Ormond Street Hospital for ChildrenNHS Foundation TrustLondonUK
| | - J. Nicholson
- Paediatric Psychosocial DepartmentRoyal Manchester Children's HospitalManchester University NHS Foundation TrustManchesterUK
| | - K. E. Cosgrove
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - M. J. Dunne
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| |
Collapse
|
36
|
Welters A, Meissner T, Grulich-Henn J, Fröhlich-Reiterer E, Warncke K, Mohnike K, Blankenstein O, Menzel U, Datz N, Bollow E, Holl RW. Characterization of diabetes following pancreatic surgery in patients with congenital hyperinsulinism. Orphanet J Rare Dis 2018; 13:230. [PMID: 30577875 PMCID: PMC6304089 DOI: 10.1186/s13023-018-0970-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 12/05/2018] [Indexed: 11/25/2022] Open
Abstract
Background Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycaemia in infancy that leads to unfavourable neurological outcome if not treated adequately. In patients with severe diffuse CHI it remains under discussion whether pancreatic surgery should be performed or intensive medical treatment with the acceptance of recurrent episodes of mild hypoglycaemia is justified. Near-total pancreatectomy is associated with high rates of insulin-dependent diabetes mellitus and exocrine pancreatic insufficiency. Little is known about the management and long-term glycaemic control of CHI patients with diabetes after pancreatic surgery. We searched the German/Austrian DPV database and compared the course of 42 CHI patients with diabetes to that of patients with type 1 diabetes mellitus (T1DM). Study groups were compared at diabetes onset and after a follow-up period of 6.1 [3.3–9.7] (median [interquartile range]) years. Results The majority of CHI patients with diabetes were treated with insulin (85.2% [70.9–99.5] at diabetes onset, and 90.5% [81.2–99.7] at follow-up). However, compared to patients with T1DM, significantly more patients in the CHI group with diabetes were treated with conventional insulin therapy (47.8% vs. 24.4%, p = 0.03 at diabetes onset, and 21.1% vs. 6.4% at follow-up, p = 0.003), and only a small number of CHI patients were treated with insulin pumps. Daily insulin dose was significantly lower in CHI patients with diabetes than in patients with T1DM, both at diabetes onset (0.3 [0.2–0.5] vs. 0.6 IE/kg/d [0.4–0.8], p = 0.003) and follow-up (0.8 [0.4–1.0] vs. 0.9 [0.7–1.0] IE/kg/d, p = 0.02), while daily carbohydrate intake was comparable in both groups. Within the first treatment year, HbA1c levels were significantly lower in CHI patients with diabetes (6.2% [5.5–7.9] vs. 7.2% [6.5–8.2], p = 0.003), but increased to a level comparable to that of T1DM patients at follow-up. Interestingly, in CHI patients, the risk of severe hypoglycaemia tends to be higher only at diabetes onset (14.8% vs. 5.8%, p = 0.1). Conclusions In surgically treated CHI patients insulin treatment needs to be intensified in order to achieve good glycaemic control. Our data furthermore emphasize the need for improved medical treatment options for patients with diazoxide- and/or octreotide-unresponsive CHI.
Collapse
Affiliation(s)
- Alena Welters
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, University Children's Hospital Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany.
| | - Thomas Meissner
- Department of General Paediatrics, Neonatology and Paediatric Cardiology, University Children's Hospital Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Jürgen Grulich-Henn
- Centre for Childhood and Adolescent Medicine (General Paediatrics), University Hospital Heidelberg, Heidelberg, Germany
| | | | - Katharina Warncke
- Department of Paediatrics, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Klaus Mohnike
- Department of Paediatrics, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Oliver Blankenstein
- Centre for Chronic Sick Children, Institute for Experimental Paediatric Endocrinology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ulrike Menzel
- Department of Paediatric Endocrinology, AKK Altonaer Kinderkrankenhaus, Hamburg, Germany
| | - Nicolin Datz
- Diabetes Centre for Children and Adolescents, Children's Hospital AUF DER BULT, Hannover, Germany
| | - Esther Bollow
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Centre for Diabetes Research (DZD), Munich, Neuherberg, Germany
| |
Collapse
|
37
|
Jia JL, Chen S, Sivarajah V, Stephens D, Cortez MA. Latitudinal differences on the global epidemiology of infantile spasms: systematic review and meta-analysis. Orphanet J Rare Dis 2018; 13:216. [PMID: 30486850 PMCID: PMC6262963 DOI: 10.1186/s13023-018-0952-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Infantile spasms represent the catastrophic, age-specific seizure type associated with acute and long-term neurological morbidity. However, due to rarity and heterogenous determination, there is persistent uncertainty of its pathophysiological and epidemiological characteristics. The purpose of the current study was to address a historically suspected latitudinal basis of infantile spasms incidence, and to interrogate a geographical basis of epidemiology, including the roles of latitude and other environmental factors, using meta-analytic and -regression methods. METHODS A systematic search was performed in Ovid MEDLINE and Embase for primary reports on infantile spasms incidence and prevalence epidemiology. RESULTS One thousand fifteen studies were screened to yield 54 eligible publications, from which 39 incidence figures and 18 prevalence figures were extracted. The pooled incidence was 0.249 cases/1000 live births. The pooled prevalence was 0.015 cases/1000 population. Univariate meta-regression determined a continental effect, with Europe demonstrating the highest onset compared from Asia (OR = 0.51, p = 0.004) and from North America (OR = 0.50, p = 0.004). Latitude was also positively correlated with incidence globally (OR = 1.02, p < 0.001). Sub-analyses determined a particularly elevated Scandinavian incidence compared to the rest of world (OR = 1.88, p < 0.001), and lack of latitudinal effect with Scandinavian exclusion (p = 0.10). Metrics of healthcare quality did not predict incidence. Multiple meta-regression determined that latitude was the key predictor of incidence (OR = 1.02, p = 0.001). CONCLUSIONS This is the first systematic epidemiological study of infantile spasms. Limitations included lack of Southern hemispheric representation, insufficient study selection and size to support some sub-continental analyses, and lack of accessible ethnic and healthcare quality data. Meta-analyses determined a novel, true geographical difference in incidence which is consistent with a latitudinal and/or ethnic contribution to epileptogenesis. These findings justify the establishment of a global registry of infantile spasms epidemiology to promote future systematic studies, clarify risk factors, and expand understanding of the pathophysiology.
Collapse
Affiliation(s)
- Jason L. Jia
- Department of Medicine, University of Toronto, 190 Elizabeth Street R. Fraser Elliott Wing, Toronto, M5G 2C4 Canada
| | - Shiyi Chen
- Child Health Evaluative Sciences Research Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Vishalini Sivarajah
- Department of Medicine, University of Toronto, 190 Elizabeth Street R. Fraser Elliott Wing, Toronto, M5G 2C4 Canada
| | - Derek Stephens
- Child Health Evaluative Sciences Research Program, SickKids Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Miguel A. Cortez
- Department of Pediatrics, Division of Neurology, University of Toronto, Toronto, Canada
- Neurosciences & Mental Health Program, Peter Gilgan Centre for Research and Learning, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8 Canada
| |
Collapse
|
38
|
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is a heterogeneous condition with dysregulated insulin secretion which persists in the presence of low blood glucose levels. It is the most common cause of severe and persistent hypoglycaemia in neonates and children. Recent advances in genetics have linked congenital HH to mutations in 14 different genes that play a key role in regulating insulin secretion (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1, PPM2, CACNA1D, FOXA2). Histologically, congenital HH can be divided into 3 types: diffuse, focal and atypical. Due to the biochemical basis of this condition, it is essential to diagnose and treat HH promptly in order to avoid the irreversible hypoglycaemic brain damage. Recent advances in the field of HH include new rapid molecular genetic testing, novel imaging methods (18F-DOPA PET/CT), novel medical therapy (long-acting octreotide formulations, mTOR inhibitors, GLP-1 receptor antagonists) and surgical approach (laparoscopic surgery). The review article summarizes the current diagnostic methods and management strategies for HH in children.
Collapse
Affiliation(s)
- Sonya Galcheva
- Dept. of Paediatrics, Varna Medical University/University Hospital "St. Marina", Varna, Bulgaria
| | - Sara Al-Khawaga
- Dept. of Paediatric Medicine, Division of Endocrinology, Sidra Medical & Research Center, Doha, Qatar
| | - Khalid Hussain
- Dept. of Paediatric Medicine, Division of Endocrinology, Sidra Medical & Research Center, Doha, Qatar.
| |
Collapse
|
39
|
Abstract
PURPOSE OF REVIEW Congenital hyperinsulinism is the most common cause of persistent hypoglycemia in infants and children. Early and appropriate recognition and treatment of hypoglycemia is vital to minimize neurocognitive impairment. RECENT FINDINGS There are at least 11 known monogenic forms of hyperinsulinism and several associated syndromes. Molecular diagnosis allows for prediction of the effectiveness of diazoxide and the likelihood of focal hyperinsulinism. Inactivating mutations in the genes encoding the ATP-sensitive potassium channel (KATP hyperinsulinism) account for 60% of all identifiable mutations, including 85% of diazoxide-unresponsive cases. Syndromes or disorders associated with hyperinsulinism include Beckwith-Wiedemann syndrome, Kabuki syndrome, Turner syndrome, and congenital disorders of glycosylation. Although focal hyperinsulinism can be cured by resection of the lesion, therapeutic options for nonfocal hyperinsulinism remain limited and include diazoxide, octreotide, long-acting somatostatin analogs, and near-total pancreatectomy. Although sirolimus has been reported to improve glycemic control in infants with diazoxide-unresponsive hyperinsulinism, the extent of improvement has been limited, and significant adverse events have been reported. SUMMARY Identification of the cause of congenital hyperinsulinism helps guide management decisions. Use of therapies with limited benefit and significant potential risks should be avoided.
Collapse
|
40
|
Bendix J, Laursen MG, Mortensen MB, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Christesen HT. Intraoperative Ultrasound: A Tool to Support Tissue-Sparing Curative Pancreatic Resection in Focal Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2018; 9:478. [PMID: 30186238 PMCID: PMC6113400 DOI: 10.3389/fendo.2018.00478] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background: Focal congenital hyperinsulinism (CHI) may be cured by resection of the focal, but often non-palpable, pancreatic lesion. The surgical challenge is to minimize removal of normal pancreatic tissue. Aim: To evaluate the results of intraoperative ultrasound-guided, tissue-sparing pancreatic resection in CHI patients at an international expert center. Methods: Retrospective study of CHI patients treated at Odense University Hospital, Denmark, between January 2010 and March 2017. Results: Of 62 consecutive patients with persistent CHI, 24 (39%) had focal CHI by histology after surgery. All patients had a paternal ABCC8 or KCNJ11 mutation and a focal lesion by 18F-DOPA-PET/CT. Intraoperative ultrasound localized the focal lesion in 16/20 patients (sensitivity 0.80), including one ectopic lesion in the duodenal wall. Intraoperative ultrasound showed no focal lesion in 11/11 patients with diffuse CH (specificity 1.0). The positive predictive value for focal histology was 1.0, negative predictive value 0.73. Tissue-sparing pancreatic resection (focal lesion enucleation, local resection of tail or uncinate process) was performed in 67% (n = 16). In 11/12 having tissue-sparing resection and intraoperative ultrasound, the location of the focal lesion was exactly identified. Eight patients had resection of the pancreatic head or head/body, four with Roux-en-Y, three with pancreatico-gastrostomy and one without reconstruction. None had severe complications to surgery. Cure of hypoglycaemia was seen in all patients after one (n = 21) or two (n = 3) pancreatic resections. Conclusion: In focal CHI, tissue-sparing pancreatic resection was possible in 67%. Intraoperative ultrasound was a helpful supplement to the mandatory use of genetics, preoperative 18F-DOPA-PET/CT and intraoperative frozen sections.
Collapse
Affiliation(s)
- Julie Bendix
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette G. Laursen
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael B. Mortensen
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
| | - Maria Melikian
- Department of Paediatric Endocrinology, Endocrine Research Centre, Moscow, Russia
| | - Evgenia Globa
- Department of Paediatric Endocrinology, Ukrainian Centre of Endocrine Surgery, Kiev, Ukraine
| | - Sönke Detlefsen
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Henrik T. Christesen
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- *Correspondence: Henrik T. Christesen
| |
Collapse
|
41
|
Christiansen CD, Petersen H, Nielsen AL, Detlefsen S, Brusgaard K, Rasmussen L, Melikyan M, Ekström K, Globa E, Rasmussen AH, Hovendal C, Christesen HT. 18F-DOPA PET/CT and 68Ga-DOTANOC PET/CT scans as diagnostic tools in focal congenital hyperinsulinism: a blinded evaluation. Eur J Nucl Med Mol Imaging 2017; 45:250-261. [PMID: 29116340 PMCID: PMC5745571 DOI: 10.1007/s00259-017-3867-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/20/2017] [Indexed: 12/12/2022]
Abstract
Purpose Focal congenital hyperinsulinism (CHI) is curable by surgery, which is why identification of the focal lesion is crucial. We aimed to determine the use of 18F–fluoro-dihydroxyphenylalanine (18F-DOPA) PET/CT vs. 68Ga-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic-acid-1-Nal3-octreotide (68Ga-DOTANOC) PET/CT as diagnostic tools in focal CHI. Methods PET/CT scans of children with CHI admitted to Odense University Hospital between August 2005 and June 2016 were retrospectively evaluated visually and by their maximal standardized uptake values (SUVmax) by two independent examiners, blinded for clinical, surgical and pathological data. Pancreatic histology was used as the gold standard. For patients without surgery, the genetic profile served as the gold standard. Results Fifty-five CHI patients were examined by PET/CT (18F-DOPA n = 53, 68Ga-DOTANOC n = 18). Surgery was performed in 34 patients, no surgery in 21 patients. Fifty-one patients had a classifiable outcome, either by histology (n = 33, 22 focal lesions, 11 non-focal) or by genetics (n = 18, all non-focal). The predictive performance of 18F-DOPA PET/CT to identify focal CHI was identical by visual- and cut-off-based evaluation: sensitivity (95% CI) of 1 (0.85–1); specificity of 0.96 (0.82–0.99). The optimal 18F-DOPA PET SUVmax ratio cut-off was 1.44 and the optimal 68Ga-DOTANOC PET SUVmax cut-off was 6.77 g/ml. The area under the receiver operating curve was 0.98 (0.93–1) for 18F-DOPA PET vs. 0.71 (0.43–0.95) for 68Ga-DOTANOC PET (p < 0.03). In patients subjected to surgery, localization of the focal lesion was correct in 91%, and 100%, by 18F-DOPA PET/CT and 68Ga-DOTANOC PET/CT, respectively. Conclusion 18F-DOPA PET/CT was excellent in predicting focal CHI and superior compared to 68Ga-DOTANOC PET/CT. Further use of 68GA-DOTANOC PET/CT in predicting focal CHI is discouraged. Electronic supplementary material The online version of this article (10.1007/s00259-017-3867-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Charlotte Dahl Christiansen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | | | - Sönke Detlefsen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- Department of Abdominal Surgery, Odense University Hospital, Odense, Denmark
| | | | - Klas Ekström
- Astrid Lindgren Children's Hospital, Karolinska Hospital, Stockholm, Sweden
| | - Evgenia Globa
- Ukrainian Center of Endocrine Surgery, Endocrine Organs and Tissue Transplantation, MOH of Ukraine, Kyiv, Ukraine
| | - Annett Helleskov Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Claus Hovendal
- Department of Abdominal Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark. .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark. .,Odense Pancreas Center (OPAC), Odense University Hospital, Odense, Denmark. .,Department of Paediatrics, Odense University Hospital, Sdr. Blvd. 29, DK-5000, Odense C, Denmark.
| |
Collapse
|