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Calcaterra V, Zuccotti G, Mari A, Iafusco F, Maione G, Iafusco D, Tinto N. Can obesity exacerbate hyperinsulinaemia in the presence of the mutation of an insulin receptor gene? Clin Obes 2023; 13:e12619. [PMID: 37717597 DOI: 10.1111/cob.12619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 09/19/2023]
Abstract
Insulin receptor gene (INSR) mutations are a relatively rare and diverse cause of insulin resistance (IR), typically associated with a lean phenotype. However, we present a unique case of severe obesity and Type A severe IR syndrome in a patient with a heterozygous mutation of the INSR gene. Next Generation Sequencing (NGS) analysis was conducted to identify the genetic variant. A 16-year-old girl with severe obesity (BMI-SDS +2.79) exhibited markedly elevated basal insulin levels (>800 mcU/L). Despite obesity being a known cause of hyperinsulinism, further investigation was pursued due to the severity of hyperinsulinaemia. A heterozygous nucleotide variant at the donor splicing site of intron 13 (c.2682 + 1G > A) of the INSR gene was identified. This mutation was also present in the proband's normal-weight mother and her two younger brothers with obesity. Metformin treatment provided limited benefits, but subsequent liraglutide therapy resulted in weight loss and decreased IR 3 months after initiation. Our findings suggest that obesity can exacerbate hyperinsulinaemia in individuals with an INSR gene mutation. Although INSR signalling defects play a minor role in the aetiology of IR, they should still be considered in the diagnostic pathway, particularly in severe phenotypes. Clinicians should not overlook the possibility of genetic causes in patients with obesity and IR, as they may require personalized management approaches.
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Affiliation(s)
- Valeria Calcaterra
- Department of Internal Medicine, University of Pavia, Pavia, Italy
- Pediatric Department, Buzzi Children's Hospital, Milan, Italy
| | - Gianvincenzo Zuccotti
- Pediatric Department, Buzzi Children's Hospital, Milan, Italy
- Department of Biomedical and Clinical Science, University of Milano, Milan, Italy
| | - Alessandra Mari
- Pediatric Department, Buzzi Children's Hospital, Milan, Italy
| | - Fernanda Iafusco
- Department of Molecular Medicine and Medical Biotechnology, University of Napoli "Federico II", Naples, Italy
- Department of Molecular Medicine and Medical Biotechnology, CEINGE Advanced Biotechnologies, Naples, Italy
| | - Giovanna Maione
- Department of Molecular Medicine and Medical Biotechnology, University of Napoli "Federico II", Naples, Italy
- Department of Molecular Medicine and Medical Biotechnology, CEINGE Advanced Biotechnologies, Naples, Italy
| | - Dario Iafusco
- Department of Pediatrics, Regional Center of Pediatric Diabetology "G.Stoppoloni", University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Nadia Tinto
- Department of Molecular Medicine and Medical Biotechnology, University of Napoli "Federico II", Naples, Italy
- Department of Molecular Medicine and Medical Biotechnology, CEINGE Advanced Biotechnologies, Naples, Italy
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Scalia P, Williams SJ, Fujita-Yamaguchi Y, Giordano A. Cell cycle control by the insulin-like growth factor signal: at the crossroad between cell growth and mitotic regulation. Cell Cycle 2023; 22:1-37. [PMID: 36005738 PMCID: PMC9769454 DOI: 10.1080/15384101.2022.2108117] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
In proliferating cells and tissues a number of checkpoints (G1/S and G2/M) preceding cell division (M-phase) require the signal provided by growth factors present in serum. IGFs (I and II) have been demonstrated to constitute key intrinsic components of the peptidic active fraction of mammalian serum. In vivo genetic ablation studies have shown that the cellular signal triggered by the IGFs through their cellular receptors represents a non-replaceable requirement for cell growth and cell cycle progression. Retroactive and current evaluation of published literature sheds light on the intracellular circuitry activated by these factors providing us with a better picture of the pleiotropic mechanistic actions by which IGFs regulate both cell size and mitogenesis under developmental growth as well as in malignant proliferation. The present work aims to summarize the cumulative knowledge learned from the IGF ligands/receptors and their intracellular signaling transducers towards control of cell size and cell-cycle with particular focus to their actionable circuits in human cancer. Furthermore, we bring novel perspectives on key functional discriminants of the IGF growth-mitogenic pathway allowing re-evaluation on some of its signal components based upon established evidences.
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Affiliation(s)
- Pierluigi Scalia
- ISOPROG-Somatolink EPFP Research Network, Philadelphia, PA, USA, Caltanissetta, Italy,CST, Biology, Sbarro Institute for Cancer Research and Molecular Medicine, Temple University, Philadelphia, PA, United states,CONTACT Pierluigi Scalia ISOPROG-Somatolink EPFP Research Network, Philadelphia, PA9102, USA
| | - Stephen J Williams
- ISOPROG-Somatolink EPFP Research Network, Philadelphia, PA, USA, Caltanissetta, Italy,CST, Biology, Sbarro Institute for Cancer Research and Molecular Medicine, Temple University, Philadelphia, PA, United states
| | - Yoko Fujita-Yamaguchi
- Arthur Riggs Diabetes & Metabolism Research Institute, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Antonio Giordano
- ISOPROG-Somatolink EPFP Research Network, Philadelphia, PA, USA, Caltanissetta, Italy,School of Medical Biotechnology, University of Siena, Italy
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Yu L, Yu F, Ma Z, Lu H, Luo J, Sun T, Liu Q, Gan S. INSR novel mutations identified in a Chinese family with severe INSR-related insulin resistance syndromes: A case report. Medicine (Baltimore) 2022; 101:e32266. [PMID: 36626508 PMCID: PMC9750703 DOI: 10.1097/md.0000000000032266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Severe insulin receptor gene (INSR)-related insulin resistance syndromes (SIR) include Donohue syndrome (DS), Rabson-Mendenhall syndrome (RMS), and type A insulin resistance. The incidence of DS is about 1 in 4 million births. We identified novel INSR mutations (c.2246delG and c.2646 + 5G > A) in a patient with SIR, which expanded the variant spectrum and helped to improve the understanding of the diagnosis and treatment of this condition. PATIENT CONCERNS A 10-year-old Chinese boy was admitted to the hospital for deepening skin color. He presented with growth retardation, peculiar facial features, acanthosis nigricans, hypertrichosis, extremely high insulin levels, fasting hypoglycemia, and postprandial hyperglycemia, Whole-exome gene testing suggested compound heterozygous mutations in INSR (c.2246delG and c.2646 + 5G > A). DIAGNOSIS The diagnosis was SIR. What's more, based on the phenotypic and biographical results, this child did not present typical RMS and DS but rather an intermediate phenotype between the 2 conditions. INTERVENTIONS On the basis of a sensible diet and exercise, the patient was prescribed metformin (250 mg) at breakfast and lunch, which was increased to 500 mg after 1 month. OUTCOMES After 2 months of treatment, the patient's glycated hemoglobin (HbA1c) levels decreased to 6% but his insulin resistance did not improve significantly. LESSONS In children who are not obese but with severe insulin resistance, growth retardation, hirsutism, and hyperglycemia, genetic testing should be performed for early diagnosis, active treatment, and follow-up.
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Affiliation(s)
- Lu Yu
- Department of Endocrinology and Metabolism, The First People’s Hospital of Changde City, Changde, Hunan, P. R. China
| | - Fang Yu
- Department of Endocrinology and Metabolism, The First People’s Hospital of Changde City, Changde, Hunan, P. R. China
| | - Zongrui Ma
- Department of Ophthalmology, The First People’s Hospital of Changde City, Changde, Hunan, P. R. China
| | - Huilin Lu
- Department of Endocrinology and Metabolism, The First People’s Hospital of Changde City, Changde, Hunan, P. R. China
| | - Jian Luo
- Department of Endocrinology and Metabolism, The First People’s Hospital of Changde City, Changde, Hunan, P. R. China
| | - Ting Sun
- Department of Endocrinology and Metabolism, The First People’s Hospital of Changde City, Changde, Hunan, P. R. China
| | - Qin Liu
- Department of Endocrinology and Metabolism, The First People’s Hospital of Changde City, Changde, Hunan, P. R. China
| | - Shenglian Gan
- Department of Endocrinology and Metabolism, The First People’s Hospital of Changde City, Changde, Hunan, P. R. China
- * Correspondence: Shenglian Gan, Department of Endocrinology and Metabolism, The First People’s Hospital of Changde City, Renmin Middle Road 818, Changde, Hunan 415000, P. R. China (e-mail: )
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You W, Yang J, Wang L, Liu Y, Wang W, Zhu L, Wang W, Yang J, Chen F. Case Report: A Chinese Family of Type A Insulin Resistance Syndrome With Diabetes Mellitus, With a Novel Heterozygous Missense Mutation of the Insulin Receptor Gene. Front Endocrinol (Lausanne) 2022; 13:895424. [PMID: 35634501 PMCID: PMC9134870 DOI: 10.3389/fendo.2022.895424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/25/2022] [Indexed: 11/13/2022] Open
Abstract
Type A Insulin resistance syndrome (TAIRS) is an autosomal dominant or recessive genetic disorder caused by insulin dysfunction resulting from insulin receptor (INSR) gene mutation. The main features of TAIRS include hyperinsulinemia, abnormal glucose metabolism, and changes in acanthosis nigricans. We identified, in China, a TAIRS family with a novel heterozygous missense gene mutation type. One patient from the Chinese Han family exhibited signs and symptoms of TAIRS and was presented for evaluation. Whole-exome sequencing revealed a heterozygous mutation. Both the patient proband and his father were identified with insulin receptor exon 19c.3472C>T(p.Arg1158Trp), which resulted in a missense mutation that led to replace by a base in the amino acid codon. We found that the patient proband and his father exhibited high insulin and C-peptide release after glucose stimulation by insulin and C-peptide release tests. At the same time, we also ruled out the possibility of islet βcell tumor through relevant examinations. These findings indicate that the INSR gene mutation may cause pancreatic β cell functional impairment and contribute to the development of diabetes.
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Zhou Q, Yu J, Yuan X, Wang C, Zhu Z, Zhang A, Gu W. Clinical and Functional Characterization of Novel INSR Variants in Two Families With Severe Insulin Resistance Syndrome. Front Endocrinol (Lausanne) 2021; 12:606964. [PMID: 33995269 PMCID: PMC8117416 DOI: 10.3389/fendo.2021.606964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/12/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Defects in the insulin receptor (INSR) gene cause various severe insulin resistance conditions, including Donohue syndrome (DS), Rabson-Mendenhall syndrome (RMS) and type A insulin resistance (type A-IR). This study aimed to investigate the clinical characterization and molecular defects in three Chinese children with INSR-related insulin resistance syndrome. METHODS We reviewed the clinical data of three Chinese children with INSR-related insulin resistance syndrome from two unrelated kindreds. Genetic analysis was performed using whole-exome sequencing and the effects of the novel variants were further assessed by in vitro functional assays. RESULTS The proband with type A-IR presented with acanthosis nigricans, hypertrichosis, and euglycemia with mild insulin resistance in early childhood. His sister presented with features typical of type A-IR and was diagnosed with diabetes mellitus with severe insulin resistance at the age of 9.8 years. The proband with DS showed typical dysmorphic characteristics, severe intrauterine growth retardation, extreme insulin resistance, fasting hypoglycemia and postprandial hyperglycemia from birth. The heterozygote variants c.[3670G>A]; c.[3614C>T] were identified in both siblings with type A-IR; and c.[749_751del]; c.[3355C>T] in the patient with DS. In vitro studies showed that the novel variant c.749_751del [p.(Thr250del)] in the α-subunit, reduced expression of the mature INSR protein and severely impaired INSR function. In contrast, the novel variant c.3670G>A [p.(Val1224Met)] in the β-subunit had no effect on total protein expression and phosphorylation of INSR and Akt, suggesting that the variant p.Val1224Met appeared to be tolerated and was not responsible for the severe insulin resistance. CONCLUSION Our study detailed the clinical features of three patients with type A-IR and DS, and identified two novel variants in the INSR gene. Functional assays indicated the novel variant p.Thr250del was pathogenic. In contrast, the novel variant p.Val1224Met was suggested to be tolerated by our experimental data, even though bioinformatics analyses predicted the variant as deleterious.
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Affiliation(s)
- Qiaoli Zhou
- Department of Endocrinology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Jing Yu
- Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Xuewen Yuan
- Department of Endocrinology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Chunli Wang
- Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Ziyang Zhu
- Department of Endocrinology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Aihua Zhang
- Nanjing Key Laboratory of Pediatrics, Children’s Hospital of Nanjing Medical University, Nanjing, China
- Department of Nephrology, Children’s Hospital of Nanjing Medical University, Nanjing, China
- Jiangsu Key Laboratory of Pediatrics, Nanjing Medical University, Nanjing, China
- *Correspondence: Wei Gu, ; Aihua Zhang,
| | - Wei Gu
- Department of Endocrinology, Children’s Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Wei Gu, ; Aihua Zhang,
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Aghababaie AS, Ford-Adams M, Buchanan CR, Arya VB, Colclough K, Kapoor RR. A novel heterozygous mutation in the insulin receptor gene presenting with type A severe insulin resistance syndrome. J Pediatr Endocrinol Metab 2020; 33:809-812. [PMID: 32441669 DOI: 10.1515/jpem-2019-0503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 03/21/2020] [Indexed: 11/15/2022]
Abstract
Background Inherited severe insulin resistance syndromes (SIRS) are rare and can be caused by mutations in the insulin receptor gene (INSR). Case presentation A 12-year-old Jamaican girl with a BMI of 24.4 kg/m2 presented with polyuria and polydipsia. A diagnosis of T1DM was made in view of hyperglycaemia (18 mmol/l), and elevated Hba1C (9.9%), and insulin therapy was initiated. Over the next 2 years, she developed hirsutism and acanthosis nigricans, and had minimal insulin requirements with frequent post-prandial hypoglycaemia. In view of this, and her strong family history suggestive of a dominantly inherited type of diabetes, the diagnosis was revisited. Targeted next-generation sequencing (NGS) of the patient's monogenic diabetes genes was performed. What is new? NGS revealed a novel heterozygous missense INSR variant, NM_000208.3:c.3471T>G, p.(His1157Gln), confirming a diagnosis of Type A SIRS. Conclusions Type A SIRS can be difficult to differentially diagnose due to the variable phenotype. Features of insulin resistance may be absent at initial presentation and may develop later during pubertal progress. Awareness of the clinical features and comprehensive genetic testing are essential to identify the condition.
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Affiliation(s)
- Arameh S Aghababaie
- Paediatric Diabetes & Endocrinology Department, King's College Hospital, London, UK.,Lewisham and Greenwich NHS Foundation TrustLondon, UK
| | | | | | - Ved B Arya
- King's College Hospital NHS Foundation Trust, London, UK
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Hacihamdioğlu B, Baş EG, Delil K. Homozygous Mutation in the Insulin Receptor Gene Associated with Mild Type A Insulin Resistance Syndrome: A Case Report. J Clin Res Pediatr Endocrinol 2020; 13:100-103. [PMID: 32018348 PMCID: PMC7947722 DOI: 10.4274/jcrpe.galenos.2020.2019.0213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 01/17/2020] [Indexed: 01/19/2023] Open
Abstract
Insulin receptor (INSR) mutations lead to heterogeneous disorders that may be as severe as Donohue syndrome or as mild as “type A insulin resistance syndrome”. Patients with severe disorders usually harbor homozygous or compound heterozygous mutations. In contrast, type A insulin resistance syndrome has been associated with heterozygous mutations; homozygous mutations are rarely responsible for this condition. We report a novel, homozygous mutation, p.Leu260Arg in exon 3, of the INSR gene in a female adolescent patient with type A insulin resistance syndrome together with clinical details of her medical follow-up. Different mutations in the INSR gene cause different phenotype and vary depending on the inheritance pattern. This report adds to the literature, increases understanding of the disease mechanism and aids in genetic counseling.
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Affiliation(s)
- Bülent Hacihamdioğlu
- İstinye University Faculty of Medicine, Department of Pediatric Endocrinology, İstanbul, Turkey
| | | | - Kenan Delil
- Marmara University Faculty of Medicine, Department of Medical Genetics, İstanbul, Turkey
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Daghestani MH. RS1799817 in INSR associates with susceptibility to polycystic ovary syndrome. J Med Biochem 2020; 39:149-59. [PMID: 33033446 DOI: 10.2478/jomb-2019-0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 04/17/2019] [Indexed: 12/18/2022] Open
Abstract
Background Insulin and its receptor (INSR) have been implicated in the etiology of the polycystic ovarian syndrome (PCOS). Here, we investigate the association between INSR rs1799817 polymorphism and PCOS in Saudi Arabian women. Methods Study group included 126 PCOS women and 118 normo-ovulatory matched controls. The demographic data was recorded, and the plasma levels of glucose, lipids, leptin, E2, LH, FSH, T, SHBG, and insulin were determined. The genotypic and allele frequencies of rs1799817 were evaluated in both PCOS and control group. Polymerase chain reaction (PCR) was used to amplify Exon 17 of the INSR gene, and the amplified products were analyzed by direct sequencing. A single-nucleotide polymorphism (C to T) was found at locus 10923 (His1058) of rs1799817. Results In the PCOS group, the mutant allele T occurs at a significantly higher frequency (0.306) compared to the control group (0.174) (p<0.001). It shows a dominant effect and elevates the relative risk of PCOS even in the heterozygotes (RR=2.82). After stratification of the participants by body mass index, the frequency of T allele was significantly higher in the lean patients with PCOS compared to the lean control. The obese PCOS also had a higher frequency than the obese control, but the difference was not statistically significant. Several parameter values were affected by the INSR genotype, particularly W/H ratio, lipid, insulin and glucose levels and insulin resistance in PCOS patients. Conclusions The INSR gene polymorphism rs1799817 is a susceptibility locus associated with PCOS in Saudis and associated metabolic and hormonal changes, particularly, in the lean PCOS females.
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Fujita S, Kuroda Y, Fukui K, Iwamoto R, Kozawa J, Watanabe T, Yamada Y, Imagawa A, Iwahashi H, Shimomura I. Hyperinsulinemia and Insulin Receptor Gene Mutation in Nonobese Healthy Subjects in Japan. J Endocr Soc 2017; 1:1351-1361. [PMID: 29264459 PMCID: PMC5686598 DOI: 10.1210/js.2017-00332] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/09/2017] [Indexed: 11/22/2022] Open
Abstract
Context: Hyperinsulinemia is often observed in obese people, owing to their insulin resistance accompanied by visceral fat accumulation, but the frequency of hyperinsulinemia in nonobese people is not well known. Mutations in the insulin receptor gene are known to cause insulin resistance and hyperinsulinemia in type A insulin resistance syndrome, Rabson-Mendenhall syndrome, and Donohue syndrome. However, insulin receptor gene abnormalities have not been investigated in asymptomatic hyperinsulinemic subjects. Purpose: The aim of the current study was to investigate the prevalence of hyperinsulinemia in nonobese Japanese subjects and to examine the involvement of insulin receptor gene mutations. Methods: We enrolled 11,046 subjects who received health checkups. From these, we extracted nonobese subjects (body mass index <25 kg/m2) who exhibited hyperinsulinemia (serum fasting immunoreactive insulin ≥15 µU/mL). Genetic analysis was performed for the insulin receptor gene in 11 nonobese subjects with hyperinsulinemia. Results: The prevalence of hyperinsulinemia without apparent diabetes in nonobese subjects was 0.4% (33/8630). In the 11 analyzed subjects, two novel heterozygous nonsense mutations were detected [c.2106 T>G (p.Y702X) and c.2779-2780 GC>A]. The prevalence of insulin receptor gene mutations was 18.2% (2/11). Conclusions: To our knowledge, this is the first report of the prevalence of hyperinsulinemia in nonobese healthy subjects. We identified two novel mutations in the insulin receptor gene. These findings indicate that mutations in the insulin receptor gene may be related to fasting hyperinsulinemia, and insulin receptor gene screening may be useful for determining the cause of unexplained hyperinsulinemia.
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Affiliation(s)
- Shingo Fujita
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan
| | - Yohei Kuroda
- Department of Endocrinology and Metabolism, Sumitomo Hospital, Osaka, 530-0005, Japan
| | - Kenji Fukui
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan
| | - Ryuya Iwamoto
- Department of Endocrinology and Metabolism, Sumitomo Hospital, Osaka, 530-0005, Japan
| | - Junji Kozawa
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan
| | | | - Yuya Yamada
- Department of Endocrinology and Metabolism, Sumitomo Hospital, Osaka, 530-0005, Japan
| | - Akihisa Imagawa
- Department of Internal Medicine (I), Osaka Medical College, Osaka, 569-8686, Japan
| | - Hiromi Iwahashi
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan.,Department of Diabetes Care Medicine, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Osaka, 565-0871, Japan
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