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Khan SA, Fakih M, Taufiq N, Ahmerin A, Bangash A, Iqbal Malik M. Clinical Spectrum of Hereditary Tyrosinemia Type 1 in a Cohort of Pakistani Children. Clin Med Insights Pediatr 2024; 18:11795565241236176. [PMID: 38456192 PMCID: PMC10919130 DOI: 10.1177/11795565241236176] [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: 05/07/2023] [Accepted: 01/30/2024] [Indexed: 03/09/2024] Open
Abstract
Background Hereditary Tyrosinemia Type 1 (HT1), a rare autosomal recessive metabolic disorder, arises from fumarylacetoacetate (FAH) enzyme deficiency, resulting in toxic metabolite buildup. It manifests in acute, subacute, and chronic forms, with early diagnosis and Nitisinone treatment being vital. Objectives The study aims to highlight the different clinical presentations of Hereditary Tyrosinemia type 1 in a cohort of Pakistani children. Design Retrospective observational study. Methodology All patients diagnosed with HT1 at Shifa International Hospital, Islamabad and Pak Emirates Military Hospital, Rawalpindi between 2010 and 2023 were included. Information was collected regarding age, gender, symptoms, physical signs, and laboratory results. Results The study identified 6 cases of HT1. The average age at presentation was 8 months, with a mean delay in diagnosis of 26.8 months. Males were 4 (66.7%) and 2 (33.3%) were females. All patients had underlying liver disease presenting as abdominal distension with hepatosplenomegaly and accompanying growth failure. Four cases presented with rickets, 2 of which had hypophosphatemic rickets. Urine for succinylacetone was raised in all patients. Alpha fetoprotein was raised but hepatocellular carcinoma was diagnosed in 1 patient only. Low protein diet, and vitamin supplements were used for management. Five of the 6 patients died within 2 years of diagnosis. Conclusion Delayed referrals and unavailability of Nitisinone are the major challenges in diagnosing and treating HT1 in Pakistan.
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Affiliation(s)
- Sabeen Abid Khan
- Shifa College of Medicine, Tameer-e-Millat University, Islamabad, Pakistan
| | - Misbah Fakih
- Shifa College of Medicine, Tameer-e-Millat University, Islamabad, Pakistan
| | - Nida Taufiq
- Pak Emirates Military Hospital, Rawalpindi, Punjab, Pakistan
| | - Afaaf Ahmerin
- Shifa College of Medicine, Tameer-e-Millat University, Islamabad, Pakistan
| | - Asfand Bangash
- Shifa College of Medicine, Tameer-e-Millat University, Islamabad, Pakistan
| | - Munir Iqbal Malik
- Shifa College of Medicine, Tameer-e-Millat University, Islamabad, Pakistan
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De Leon DD, Arnoux JB, Banerjee I, Bergada I, Bhatti T, Conwell LS, Fu J, Flanagan SE, Gillis D, Meissner T, Mohnike K, Pasquini TL, Shah P, Stanley CA, Vella A, Yorifuji T, Thornton PS. International Guidelines for the Diagnosis and Management of Hyperinsulinism. Horm Res Paediatr 2023:000531766. [PMID: 37454648 PMCID: PMC11124746 DOI: 10.1159/000531766] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 05/16/2023] [Indexed: 07/18/2023] Open
Abstract
Hyperinsulinism (HI) due to dysregulation of pancreatic beta-cell insulin secretion is the most common and most severe cause of persistent hypoglycemia in infants and children. In the 65 years since HI in children was first described, there has been a dramatic advancement in the diagnostic tools available, including new genetic techniques and novel radiologic imaging for focal HI, however; there have been almost no new therapeutic modalities since the development of diazoxide. Recent advances in neonatal research and genetics have improved our understanding of the pathophysiology of both transient and persistent forms of neonatal hyperinsulinism. Rapid turnaround of genetic test results combined with advanced radiologic imaging can permit identification and localization of surgically-curable focal lesions in a large proportion of children with congenital forms of HI, but are only available in certain centers in 'developed' countries. Diazoxide, the only drug currently approved for treating HI, was recently designated as an "essential medicine" by the World Health Organization but has been approved in only 16% of Latin American countries and remains unavailable in many under-developed areas of the world. Novel treatments for HI are emerging, but they await completion of safety and efficacy trials before being considered for clinical use. This international consensus statement on diagnosis and management of HI was developed in order to assist specialists, general pediatricians, and neonatologists in early recognition and treatment of HI with the ultimate aim of reducing the prevalence of brain injury caused by hypoglycemia. A previous statement on diagnosis and management of HI in Japan was published in 2017. The current document provides an updated guideline for management of infants and children with HI and includes potential accommodations for less-developed regions of the world where resources may be limited.
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Affiliation(s)
- Diva D. De Leon
- Congenital Hyperinsulinism Center and Division of Endocrinology and Diabetes, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jean Baptiste Arnoux
- Reference Center for Inherited Metabolic Diseases, Necker-Enfants Malades Hospital, AP-HP, University of Paris-Cité, Paris, France
| | - Indraneel Banerjee
- Paediatric Endocrinology, Royal Manchester Children’s Hospital, University of Manchester, Manchester, UK
| | - Ignacio Bergada
- Centro de Investigaciones Endocrinológicas “Dr. César Bergadá” (CONICET – FEI), Division de Endrocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Tricia Bhatti
- Department of Clinical Pathology and Laboratory Medicine, Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Louise S. Conwell
- Australia and Children’s Health Queensland Clinical Unit, Department of Endocrinology and Diabetes, Queensland Children’s Hospital, Children’s Health Queensland, Greater Brisbane Clinical School, Medical School, Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Junfen Fu
- National Clinical Research Center for Child Health, Department of Endocrinology, The Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Sarah E. Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - David Gillis
- Hadassah Medical Center, Department of Pediatrics, Ein-Kerem, Jerusalem and Faculty of Medicine, Hebrew-University, Jerusalem, Israel
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children’s Hospital, Medical Faculty, Heinrich Heine University, Duesseldorf, Germany
| | - Klaus Mohnike
- Department of General Pediatrics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Tai L.S. Pasquini
- Research and Policy Director, Congenital Hyperinsulinism International, Glen Ridge, NJ, USA
| | - Pratik Shah
- Pediatric Endocrinology, The Royal London Children’s Hospital, Queen Mary University of London, London, UK
| | - Charles A. Stanley
- Congenital Hyperinsulinism Center and Division of Endocrinology and Diabetes, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Adrian Vella
- Division of Diabetes, Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Tohru Yorifuji
- Pediatric Endocrinology and Metabolism, Children’s Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Paul S. Thornton
- Congenital Hyperinsulinism Center, Cook Children’s Medical Center and Texas Christian University Burnett School of Medicine, Fort Worth, TX, USA
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Zenker M, Mohnike K, Palm K. Syndromic forms of congenital hyperinsulinism. Front Endocrinol (Lausanne) 2023; 14:1013874. [PMID: 37065762 PMCID: PMC10098214 DOI: 10.3389/fendo.2023.1013874] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 03/07/2023] [Indexed: 04/18/2023] Open
Abstract
Congenital hyperinsulinism (CHI), also called hyperinsulinemic hypoglycemia (HH), is a very heterogeneous condition and represents the most common cause of severe and persistent hypoglycemia in infancy and childhood. The majority of cases in which a genetic cause can be identified have monogenic defects affecting pancreatic β-cells and their glucose-sensing system that regulates insulin secretion. However, CHI/HH has also been observed in a variety of syndromic disorders. The major categories of syndromes that have been found to be associated with CHI include overgrowth syndromes (e.g. Beckwith-Wiedemann and Sotos syndromes), chromosomal and monogenic developmental syndromes with postnatal growth failure (e.g. Turner, Kabuki, and Costello syndromes), congenital disorders of glycosylation, and syndromic channelopathies (e.g. Timothy syndrome). This article reviews syndromic conditions that have been asserted by the literature to be associated with CHI. We assess the evidence of the association, as well as the prevalence of CHI, its possible pathophysiology and its natural course in the respective conditions. In many of the CHI-associated syndromic conditions, the mechanism of dysregulation of glucose-sensing and insulin secretion is not completely understood and not directly related to known CHI genes. Moreover, in most of those syndromes the association seems to be inconsistent and the metabolic disturbance is transient. However, since neonatal hypoglycemia is an early sign of possible compromise in the newborn, which requires immediate diagnostic efforts and intervention, this symptom may be the first to bring a patient to medical attention. As a consequence, HH in a newborn or infant with associated congenital anomalies or additional medical issues remains a differential diagnostic challenge and may require a broad genetic workup.
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Affiliation(s)
- Martin Zenker
- Institute of Human Genetics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- *Correspondence: Martin Zenker,
| | - Klaus Mohnike
- Department of Pediatrics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Katja Palm
- Department of Pediatrics, University Hospital, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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Evaluation of dynamic thiol/disulfide homeostasis in hereditary tyrosinemia type 1 patients. Pediatr Res 2022; 92:474-479. [PMID: 34628487 DOI: 10.1038/s41390-021-01770-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 07/29/2021] [Accepted: 08/08/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Despite successful treatment with nitisinone, the pathophysiology of long-term complications, including hepatocellular carcinoma and mental decline in tyrosinemia type 1 patients, is still obscure. Oxidative stress may play a role in these complications. While increased fumarylacetoacetate and maleylacetoacetate cause oxidative stress in the liver, increased tyrosine causes oxidative stress in the brain. The aim of this study is to evaluate dynamic thiol/disulfide homeostasis as an indicator of oxidative stress in late-diagnosed tyrosinemia type 1 patients. METHODS Twenty-four late-diagnosed (age of diagnosis; 14.43 ± 26.35 months) tyrosinemia type 1 patients (19 under nitisinone treatment and 5 with liver transplantation) and 25 healthy subjects were enrolled in the study. Serum native thiol, total thiol, and disulfide levels were measured, and disulfide/native, disulfide/total, and native thiol/total thiol ratios were calculated from these values. RESULTS No significant difference was observed in native, total, and disulfide thiol levels between the groups and no increase in disulfide/native, disulfide/total, and native/total thiol ratios was detected, despite significantly higher plasma tyrosine levels in the nitisinone-treated group. CONCLUSIONS We suggest that providing sufficient metabolic control with good compliance to nitisinone treatment can help to prevent oxidative stress in late-diagnosed tyrosinemia type 1 patients. IMPACT Despite successful nitisinone (NTBC) treatment, the underlying mechanisms of long-term complications in hereditary tyrosinemia type 1 (HT1), including hepatocellular carcinoma and mental decline, are still obscure. Oxidative stress may play a role in these complications. Thiol/disulfide homeostasis, which is an indicator of oxidative stress, is not disturbed in hereditary tyrosinemia patients under NTBC treatment, despite higher plasma tyrosine levels and patients who had liver transplantation. This is the first study evaluating dynamic thiol/disulfide homeostasis as an indicator of oxidative stress in late-diagnosed HT1 patients.
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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.
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Hereditary Tyrosinemia Type 1 in Jordan: A Retrospective Study. Int J Pediatr 2021; 2021:3327277. [PMID: 34899923 PMCID: PMC8660245 DOI: 10.1155/2021/3327277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/02/2021] [Accepted: 11/03/2021] [Indexed: 11/23/2022] Open
Abstract
Background Hereditary tyrosinemia type 1 (HT1) is a recessively inherited inborn error of metabolism affecting the final step of tyrosine catabolism. The accumulation of tyrosine toxic metabolites leads to progressive hepatic, renal, and neurological manifestations. Treatment of HT1 consists of tyrosine-restricted diets and nitisinone. The untreated disease progresses into life-threatening liver failure with an increased risk of hepatocellular carcinoma. Methods From April 2010 to March 2021, eighteen patients were diagnosed with HT1 in the metabolic department at Queen Rania Al Abdullah Hospital for Children in Jordan. Patients were reviewed retrospectively regarding their clinical features, laboratory data, and sociodemographic history. Results The mean age of nine boys and nine girls was 6.03 years (SD ± 3.85). The mean age for symptom onset was 5.61 months (SD ± 6.02). However, the diagnosis was belated from the onset by 10.50 months (±10.42). Nitisinone treatment was delayed from diagnosis around 12.28 months (SD ± 25.36). Most of the patients (66.7%) had acute onset of the disease. Two children (11.1%) died due to hepatic complications. Positive family history was identified in 61.1% of patients, and a similar percentage were born to parents with consanguineous marriage. The most common presentation was abdominal pain, vomiting, and fever. Hepatomegaly and abdominal distention were the most common findings. Six patients' (42.9%) first presentation was rickets. Conclusion HT1 diagnosis is usually delayed because it is not part of newborn screening and nonfamiliarity with the clinical features of the disease. Therefore, nationwide newborn screening should be expanded to include HT1.
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Yilmaz O, Daly A, Pinto A, Ashmore C, Evans S, Gupte G, Jackson R, Yabanci Ayhan N, MacDonald A. Physical Growth of Patients with Hereditary Tyrosinaemia Type I: A Single-Centre Retrospective Study. Nutrients 2021; 13:nu13093070. [PMID: 34578949 PMCID: PMC8472760 DOI: 10.3390/nu13093070] [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] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 12/23/2022] Open
Abstract
In a retrospective review, we aimed to assess long-term growth in 17 patients (n = 11 males) with hereditary tyrosinaemia type I (HTI). Median age at assessment was 15.6 years (5.7-26.6 years) and median age at diagnosis was 1 month (range: 0-16 months), with 35% (n = 6/17) symptomatic on presentation. From the age of 8 years, there was a noticeable change in median height, weight, and body-mass-index [BMI]-z-scores. Median height-for-age z-scores were consistently ≤ -1 (IQR -1.6, -0.5) during the first 8 years of life but increased with age. Weight-for-age z-scores ranged between -1 to 0 (IQR -1.2, 0.1) in the first 8 years; then increased to > 0.5 (IQR -0.3, 1.3) by age 16 years, and BMI-for-age z-scores ranged from 0 to 1 (IQR -0.7, 1.3) up to 8 years, and >1 (IQR -0.2, 1.9) until 16 years. The percentage of overweight and obesity was lowest in children aged < 5 years, and consistently > 40% in patients aged between 7 to 16 years. The prescribed total protein intake was associated with improved height growth (p < 0.01). Impaired growth in early life improved with age achieving normal population standards. Further studies are needed to investigate factors that influence growth outcome in HTI patients.
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Affiliation(s)
- Ozlem Yilmaz
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara Yildirim Beyazit University, Ankara 06760, Turkey
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara 06290, Turkey;
| | - Anne Daly
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Alex Pinto
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Catherine Ashmore
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Sharon Evans
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Girish Gupte
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
| | - Richard Jackson
- Cancer Research UK Liverpool Cancer Trials Unit, University of Liverpool, Liverpool L69 3GL, UK;
| | - Nurcan Yabanci Ayhan
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Ankara University, Ankara 06290, Turkey;
| | - Anita MacDonald
- Birmingham Women’s and Children’s Hospital, Birmingham B4 6NH, UK; (O.Y.); (A.D.); (A.P.); (C.A.); (S.E.); (G.G.)
- Correspondence: ; Tel.: +01213338024
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Hoermann H, Roeper M, Salimi Dafsari R, Koestner F, Reinauer C, Mayatepek E, Meissner T, Kummer S. Challenges in management of transient hyperinsulinism - a retrospective analysis of 36 severely affected children. J Pediatr Endocrinol Metab 2021; 34:867-875. [PMID: 33860651 DOI: 10.1515/jpem-2020-0639] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/12/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Transient hyperinsulinism (THI) is a hypoglycemia disorder which resolves spontaneously within the first weeks or months of life. The pathomechanism of THI is not elucidated yet; however, it is known that perinatal stress predisposes for THI. We aimed to characterize the clinical phenotype and treatment of children with THI, and to identify options for improved management. METHODS A retrospective analysis of 36 children with THI treated at the University Children's Hospital Düsseldorf between 2007 and 2019 was performed. RESULTS All children had risk factors for neonatal hypoglycemia or indicators of perinatal stress. Eighty three percent were diagnosed with hypoglycemia on day of life (DOL)1. None of the six diagnosed later had routine blood glucose screening and showed significantly lower blood glucose levels at the time of first blood glucose measurement compared to the children diagnosed on DOL1. Ninety seven percent of all children received intravenous glucose, 42% received continuous glucagon and 81% were started on diazoxide. Diazoxide withdrawal and subsequent fasting tests lacked standardization and were based on clinical experience. Three patients had a subsequent episode of hypoglycemia, after fasting studies only demonstrated "clinical" remission without proving the ability to ketogenesis. CONCLUSIONS Any kind of perinatal stress might pose a risk to develop THI, and postnatal monitoring for hypoglycemia still needs to be improved. Diazoxide is effective in children with THI; however, further studies are needed to guide the development of criteria and procedures for the initiation and discontinuation of treatment. Furthermore, establishing consensus diagnostic criteria/definitions for THI would improve comparability between studies.
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Affiliation(s)
- Henrike Hoermann
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Marcia Roeper
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Roschan Salimi Dafsari
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Felix Koestner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Christina Reinauer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Ertan Mayatepek
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Sebastian Kummer
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Children's Hospital, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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Sethuram S, Sperling MA, Gujral J, Romero CJ. Neonatal hyperinsulinism in transient and classical forms of tyrosinemia. Orphanet J Rare Dis 2021; 16:190. [PMID: 33910593 PMCID: PMC8082838 DOI: 10.1186/s13023-020-01642-y] [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: 06/09/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The spectrum of disorders associated with hyperinsulinemic hypoglycemia (HHI) has vastly increased over the past 20 years with identification of molecular, metabolic and cellular pathways involved in the regulation of insulin secretion and its actions. Hereditary tyrosinemia (HT1) is a rare metabolic disorder associated with accumulation of toxic metabolites of the tyrosine pathway due to a genetically mediated enzyme defect of fumarylacetoacetate hydrolase. Transient tyrosinemia of the newborn (TTN) is a benign condition with a maturational defect of the enzymes associated with tyrosine metabolism without any genetic abnormalities. RESULTS We describe two rare cases of HHI, one in a patient with HT1 and for the first time, in a patient with TTN. Each of our patients presented in the neonatal period with persistent hypoglycemia that on biochemical evaluation was consistent with HHI. Each patient received diazoxide therapy for 3.5 months and 17 months of life, respectively and HHI resolved thereafter. CONCLUSION Despite the fact that HHI has been described in HT1 for several decades, no specific mechanism has been delineated. Although we considered the common embryonal origin of the liver and pancreas with the hepatotoxic effect in HT1 also impacting the latter, this was not a possible explanation for TTN. The commonality between our two patients is the accumulation of certain amino acids which are known to be insulinotropic. We therefore hypothesize that the excess of amino acids such as leucine, lysine, valine and isoleucine in our patients resulted in HHI, which was transient. Both patients responded to diazoxide. This novel presentation in TTN and the reassuring response in both HT1 and TTN to diazoxide will be useful to inform physicians about managing HHI in these patients. Further studies are required to delineate the mechanism of HHI in these infants.
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Affiliation(s)
- Swathi Sethuram
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1616, New York, NY, 10029, USA.
| | - Mark A Sperling
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1616, New York, NY, 10029, USA
| | - Jasmine Gujral
- Division of Pediatric Endocrinology, Yale School of Medicine, New Haven, CT, USA
| | - Christopher J Romero
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1616, New York, NY, 10029, USA
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Nasir S, Raza M, Siddiqui SI, Saleem A, Abbas A. Hereditary Tyrosinemia Compounded With Hyperinsulinemic Hypoglycemia: Challenging Diagnosis of a Rare Case. Cureus 2020; 12:e11541. [PMID: 33365210 PMCID: PMC7748566 DOI: 10.7759/cureus.11541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hereditary tyrosinemia type 1 (HT-1) is a rare autosomal recessive disorder caused by a deficiency in the enzyme fumarylacetoacetate hydrolase (FAH), which catalyzes the final step in the tyrosine degradation pathway. Hereditary tyrosinemia is a heterogeneous disease with a wide spectrum of clinical manifestations involving hepatic, renal, or nervous systems. It has grave consequences if left untreated. Some of the late complications of hereditary tyrosinemia include cirrhosis, liver nodules, hepatocellular carcinoma, hypophosphatemic rickets, nephrocalcinosis, glomerulosclerosis, and chronic renal failure. Rarely, infants with hereditary tyrosinemia may present with persistent hypoglycemia, which may be a result of acute liver failure or hyperinsulinism. Hyperinsulinemic hypoglycemia (HH), caused by dysregulation of insulin secretion from pancreatic β-cells, leads to insulin driven glucose entry into the tissues and inhibits glycolysis, gluconeogenesis, fatty acid release, and ketone body synthesis. Hyperinsulinemic hypoglycemia can cause severe, persistent hypoketotic hypoglycemia. Diagnosing tyrosinemia type 1 can be a challenge as it is a heterogeneous disorder with a wide variety of clinical manifestations and complications. We herein report a rare case of a three-day-old male neonate with HT-1 compounded with HH.
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Affiliation(s)
- Sharmeen Nasir
- Pediatrics, Dow University of Health Sciences, Karachi, PAK
| | - Mohammad Raza
- Pediatrics, Dow University of Health Sciences, Karachi, PAK.,Pediatrics, Civil Hospital Karachi, Karachi, PAK
| | - Samrah I Siddiqui
- Pediatrics, Dow University of Health Sciences, Karachi, PAK.,Pediatrics, Civil Hospital Karachi, Karachi, PAK
| | - Ayesha Saleem
- Pediatrics, Dow University of Health Sciences, Karachi, PAK.,Pediatrics, Civil Hospital Karachi, Karachi, PAK
| | - Awais Abbas
- Pediatrics, Dow University of Health Sciences, Karachi, PAK.,Pediatrics, Civil Hospital Karachi, Karachi, PAK
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11
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Priestley JRC, Alharbi H, Callahan KP, Guzman H, Payan-Walters I, Smith L, Ficicioglu C, Ganetzky RD, Ahrens-Nicklas RC. The Importance of Succinylacetone: Tyrosinemia Type I Presenting with Hyperinsulinism and Multiorgan Failure Following Normal Newborn Screening. Int J Neonatal Screen 2020; 6:39. [PMID: 32832707 PMCID: PMC7422996 DOI: 10.3390/ijns6020039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/14/2020] [Indexed: 11/16/2022] Open
Abstract
Tyrosinemia type 1 (TT1) is an inborn error of tyrosine metabolism with features including liver dysfunction, cirrhosis, and hepatocellular carcinoma; renal dysfunction that may lead to failure to thrive and bone disease; and porphyric crises. Once fatal in most infantile-onset cases, pre-symptomatic diagnosis through newborn screening (NBS) protocols, dietary management, and pharmacotherapy with nitisinone have improved outcomes. Succinylacetone provides a sensitive and specific marker for the detection of TT1 but is not universally utilized in screening protocols for the disease. Here, we report an infant transferred to our facility for evaluation and management of hyperinsulinism who subsequently developed acute-onset liver, respiratory, and renal failure around one month of life. She was found to have TT1 caused by novel pathogenic variant in fumarylacetoacetate hydrolase (c.1014 delC, p.Cys 338 Ter). Her NBS, which utilized tyrosine as a primary marker, had been reported as normal, with a tyrosine level of 151 μmol/L (reference: < 280 μmol/L). Retrospective analysis of dried blood spot samples via tandem mass spectrometry showed detectable succinylacetone ranging 4.65-10.34 μmol/L. To our knowledge, this is the first patient with TT1 whose initial presenting symptom was hyperinsulinemic hypoglycemia. The case highlights the importance of maintaining a high suspicion for metabolic disease in critically ill children, despite normal NBS. We also use the case to advocate for NBS for TT1 using succinylacetone quantitation.
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Affiliation(s)
- Jessica R. C. Priestley
- Department of Pediatrics, Division of Human Genetics, Section of Biochemical Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (H.A.); (I.P.-W.); (L.S.); (C.F.); (R.D.G.); (R.C.A.-N.)
- Department of Pediatrics, Pediatric Residency Program, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Hana Alharbi
- Department of Pediatrics, Division of Human Genetics, Section of Biochemical Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (H.A.); (I.P.-W.); (L.S.); (C.F.); (R.D.G.); (R.C.A.-N.)
| | - Katharine Press Callahan
- Department of Pediatrics, Division of Neonatology, Children’s Hospital of Philadelphia, PA 19104, USA;
| | - Herodes Guzman
- Department of Pediatrics, Pediatric Residency Program, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
| | - Irma Payan-Walters
- Department of Pediatrics, Division of Human Genetics, Section of Biochemical Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (H.A.); (I.P.-W.); (L.S.); (C.F.); (R.D.G.); (R.C.A.-N.)
| | - Ligia Smith
- Department of Pediatrics, Division of Human Genetics, Section of Biochemical Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (H.A.); (I.P.-W.); (L.S.); (C.F.); (R.D.G.); (R.C.A.-N.)
| | - Can Ficicioglu
- Department of Pediatrics, Division of Human Genetics, Section of Biochemical Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (H.A.); (I.P.-W.); (L.S.); (C.F.); (R.D.G.); (R.C.A.-N.)
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Rebecca D. Ganetzky
- Department of Pediatrics, Division of Human Genetics, Section of Biochemical Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (H.A.); (I.P.-W.); (L.S.); (C.F.); (R.D.G.); (R.C.A.-N.)
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Rebecca C. Ahrens-Nicklas
- Department of Pediatrics, Division of Human Genetics, Section of Biochemical Genetics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (H.A.); (I.P.-W.); (L.S.); (C.F.); (R.D.G.); (R.C.A.-N.)
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
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Rosenfeld E, Ganguly A, De Leon DD. Congenital hyperinsulinism disorders: Genetic and clinical characteristics. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 181:682-692. [PMID: 31414570 DOI: 10.1002/ajmg.c.31737] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 07/13/2019] [Accepted: 07/29/2019] [Indexed: 12/11/2022]
Abstract
Congenital hyperinsulinism (HI) is the most frequent cause of persistent hypoglycemia in infants and children. Delays in diagnosis and initiation of appropriate treatment contribute to a high risk of neurocognitive impairment. HI represents a heterogeneous group of disorders characterized by dysregulated insulin secretion by the pancreatic beta cells, which in utero, may result in somatic overgrowth. There are at least nine known monogenic forms of HI as well as several syndromic forms. Molecular diagnosis allows for prediction of responsiveness to medical treatment and likelihood of surgically-curable focal hyperinsulinism. Timely genetic mutation analysis has thus become standard of care. However, despite significant advances in our understanding of the molecular basis of this disorder, the number of patients without an identified genetic diagnosis remains high, suggesting that there are likely additional genetic loci that have yet to be discovered.
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Affiliation(s)
- Elizabeth Rosenfeld
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Arupa Ganguly
- Department of Genetics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Diva D De Leon
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Korner J, Cline GW, Slifstein M, Barba P, Rayat GR, Febres G, Leibel RL, Maffei A, Harris PE. A role for foregut tyrosine metabolism in glucose tolerance. Mol Metab 2019; 23:37-50. [PMID: 30876866 PMCID: PMC6479665 DOI: 10.1016/j.molmet.2019.02.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 02/14/2019] [Accepted: 02/24/2019] [Indexed: 01/13/2023] Open
Abstract
Objective We hypothesized that DA and L-DOPA derived from nutritional tyrosine and the resultant observed postprandial plasma excursions of L-DOPA and DA might affect glucose tolerance via their ability to be taken-up by beta cells and inhibit glucose-stimulated β-cell insulin secretion. Methods To investigate a possible circuit between meal-stimulated 3,4-dihydroxy-L-phenylalanine (L-DOPA) and dopamine (DA) production in the GI tract and pancreatic β-cells, we: 1) mapped GI mucosal expression of tyrosine hydroxylase (TH) and aromatic amino acid decarboxylase (AADC); 2) measured L-DOPA and DA content of GI mucosal tissues following meal challenges with different L-tyrosine (TYR) content, 3) determined whether meal TYR content impacts plasma insulin and glucose excursions; and 4) characterized postprandial plasma excursions of L-DOPA and DA in response to meal tyrosine content in rodents and a population of bariatric surgery patients. Next, we characterized: 1) the metabolic transformation of TYR and L-DOPA into DA in vitro using purified islet tissue; 2) the metabolic transformation of orally administrated stable isotope labeled TYR into pancreatic DA, and 3) using a nuclear medicine technique, we studied endocrine beta cells in situ release and binding of DA in response to a glucose challenge. Results We demonstrate in rodents that intestinal content and circulatory concentrations L-DOPA and DA, plasma glucose and insulin are responsive to the tyrosine (TYR) content of a test meal. Intestinal expression of two enzymes, Tyrosine hydroxylase (TH) and Aromatic Amino acid Decarboxylase (AADC), essential to the transformation of TYR to DA was mapped and the metabolism of metabolism of TYR to DA was traced in human islets and a rodent beta cell line in vitro and from gut to the pancreas in vivo. Lastly, we show that β cells secrete and bind DA in situ in response to glucose stimulation. Conclusions We provide proof-of-principle evidence for the existence of a novel postprandial circuit of glucose homeostasis dependent on nutritional tyrosine. DA and L-DOPA derived from nutritional tyrosine may serve to defend against hypoglycemia via inhibition of glucose-stimulated β-cell insulin secretion as proposed by the anti-incretin hypothesis. Nutritional tyrosine is metabolized to L DOPA and DA in the foregut. Postprandial L-DOPA and DA plasma concentrations rise in response to tyrosine. Oral stable isotope labeled tyrosine is found postprandially in the pancreas as DA. L-DOPA and DA are inhibitors of beta cell glucose-stimulated insulin secretion. Postprandial L-DOPA and DA excursions are muted in certain bariatric surgery patients.
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Affiliation(s)
- Judith Korner
- Department of Medicine and the Naomi Berrie Diabetes Center, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Gary W Cline
- Yale Diabetes Research Center, Yale School of Medicine, New Haven, CT, 06520, USA
| | - Mark Slifstein
- Department of Psychiatry, Stony Brook University, Stony Brook, New York, NY, 11794, USA
| | - Pasquale Barba
- Institute of Genetics and Biophysics, Adriano Buzzati-Traverso, CNR, Naples, IT 80131, Italy
| | - Gina R Rayat
- Alberta Diabetes Institute, Ray Rajotte Surgical-Medical Research Institute, Department of Surgery, University of Alberta, Edmonton, AB, T6G 2E1 CA, Canada
| | - Gerardo Febres
- Department of Medicine and the Naomi Berrie Diabetes Center, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Rudolph L Leibel
- Department of Medicine and the Naomi Berrie Diabetes Center, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Antonella Maffei
- Department of Medicine and the Naomi Berrie Diabetes Center, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Paul E Harris
- Department of Medicine and the Naomi Berrie Diabetes Center, Columbia University, College of Physicians and Surgeons, New York, NY, 10032, USA.
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Galcheva S, Demirbilek H, Al-Khawaga S, Hussain K. The Genetic and Molecular Mechanisms of Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2019; 10:111. [PMID: 30873120 PMCID: PMC6401612 DOI: 10.3389/fendo.2019.00111] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/06/2019] [Indexed: 12/13/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a heterogenous and complex disorder in which the unregulated insulin secretion from pancreatic beta-cells leads to hyperinsulinaemic hypoglycaemia. The severity of hypoglycaemia varies depending on the underlying molecular mechanism and genetic defects. The genetic and molecular causes of CHI include defects in pivotal pathways regulating the secretion of insulin from the beta-cell. Broadly these genetic defects leading to unregulated insulin secretion can be grouped into four main categories. The first group consists of defects in the pancreatic KATP channel genes (ABCC8 and KCNJ11). The second and third categories of conditions are enzymatic defects (such as GDH, GCK, HADH) and defects in transcription factors (for example HNF1α, HNF4α) leading to changes in nutrient flux into metabolic pathways which converge on insulin secretion. Lastly, a large number of genetic syndromes are now linked to hyperinsulinaemic hypoglycaemia. As the molecular and genetic basis of CHI has expanded over the last few years, this review aims to provide an up-to-date knowledge on the genetic causes of CHI.
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Affiliation(s)
- Sonya Galcheva
- Department of Paediatrics, University Hospital St. Marina, Varna Medical University, Varna, Bulgaria
| | - Hüseyin Demirbilek
- Department of Paediatric Endocrinology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sara Al-Khawaga
- Division of Endocrinology, Department of Paediatric Medicine, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Division of Endocrinology, Department of Paediatric Medicine, Sidra Medicine, Doha, Qatar
- *Correspondence: Khalid Hussain
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van Ginkel WG, Rodenburg IL, Harding CO, Hollak CEM, Heiner-Fokkema MR, van Spronsen FJ. Long-Term Outcomes and Practical Considerations in the Pharmacological Management of Tyrosinemia Type 1. Paediatr Drugs 2019; 21:413-426. [PMID: 31667718 PMCID: PMC6885500 DOI: 10.1007/s40272-019-00364-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Tyrosinemia type 1 (TT1) is a rare metabolic disease caused by a defect in tyrosine catabolism. TT1 is clinically characterized by acute liver failure, development of hepatocellular carcinoma, renal and neurological problems, and consequently an extremely poor outcome. This review showed that the introduction of 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexanedione (NTBC) in 1992 has revolutionized the outcome of TT1 patients, especially when started pre-clinically. If started early, NTBC can prevent liver failure, renal problems, and neurological attacks and decrease the risk for hepatocellular carcinoma. NTBC has been shown to be safe and well tolerated, although the long-term effectiveness of treatment with NTBC needs to be awaited. The high tyrosine concentrations caused by treatment with NTBC could result in ophthalmological and skin problems and requires life-long dietary restriction of tyrosine and its precursor phenylalanine, which could be strenuous to adhere to. In addition, neurocognitive problems have been reported since the introduction of NTBC, with hypothesized but as yet unproven pathophysiological mechanisms. Further research should be done to investigate the possible relationship between important clinical outcomes and blood concentrations of biochemical parameters such as phenylalanine, tyrosine, succinylacetone, and NTBC, and to develop clear guidelines for treatment and follow-up with reliable measurements. This all in order to ultimately improve the combined NTBC and dietary treatment and limit possible complications such as hepatocellular carcinoma development, neurocognitive problems, and impaired quality of life.
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Affiliation(s)
- Willem G. van Ginkel
- Department of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
| | - Iris L. Rodenburg
- Department of Dietetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cary O. Harding
- Department of Molecular and Medical Genetics, Oregon Health & Science University, Portland, USA
| | - Carla E. M. Hollak
- Deparment of Endocrinology and Metabolism, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M. Rebecca Heiner-Fokkema
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Francjan J. van Spronsen
- Department of Metabolic Diseases, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB Groningen, The Netherlands
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Laver TW, Wakeling MN, Hua JHY, Houghton JAL, Hussain K, Ellard S, Flanagan SE. Comprehensive screening shows that mutations in the known syndromic genes are rare in infants presenting with hyperinsulinaemic hypoglycaemia. Clin Endocrinol (Oxf) 2018; 89:621-627. [PMID: 30238501 PMCID: PMC6283248 DOI: 10.1111/cen.13841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/13/2018] [Accepted: 08/20/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Hyperinsulinaemic hypoglycaemia (HH) can occur in isolation or more rarely feature as part of a syndrome. Screening for mutations in the "syndromic" HH genes is guided by phenotype with genetic testing used to confirm the clinical diagnosis. As HH can be the presenting feature of a syndrome, it is possible that mutations will be missed as these genes are not routinely screened in all newly diagnosed individuals. We investigated the frequency of pathogenic variants in syndromic genes in infants with HH who had not been clinically diagnosed with a syndromic disorder at referral for genetic testing. DESIGN We used genome sequencing data to assess the prevalence of mutations in syndromic HH genes in an international cohort of patients with HH of unknown genetic cause. PATIENTS We undertook genome sequencing in 82 infants with HH without a clinical diagnosis of a known syndrome at referral for genetic testing. MEASUREMENTS Within this cohort, we searched for the genetic aetiologies causing 20 different syndromes where HH had been reported as a feature. RESULTS We identified a pathogenic KMT2D variant in a patient with HH diagnosed at birth, confirming a genetic diagnosis of Kabuki syndrome. Clinical data received following the identification of the mutation highlighted additional features consistent with the genetic diagnosis. Pathogenic variants were not identified in the remainder of the cohort. CONCLUSIONS Pathogenic variants in the syndromic HH genes are rare; thus, routine testing of these genes by molecular genetics laboratories is unlikely to be justified in patients without syndromic phenotypes.
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Affiliation(s)
- Thomas W. Laver
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
| | - Matthew N. Wakeling
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
| | | | - Jayne A. L. Houghton
- Department of Molecular GeneticsRoyal Devon and Exeter NHS Foundation TrustExeterUK
| | - Khalid Hussain
- Department of Pediatric MedicineDivision of EndocrinologySidra MedicineDohaQatar
| | - Sian Ellard
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
| | - Sarah E. Flanagan
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
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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.
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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.
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Gokay S, Ustkoyuncu PS, Kardas F, Kendirci M. The outcome of seven patients with hereditary tyrosinemia type 1. J Pediatr Endocrinol Metab 2016; 29:1151-1157. [PMID: 27682708 DOI: 10.1515/jpem-2015-0471] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 07/18/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hereditary tyrosinemia type 1 (HT1) is a rare, inborn error of tyrosine metabolism. It is a fatal disorder without treatment. Early treatment may prevent acute liver failure, renal dysfunction, liver cirrhosis, hepatocellular carcinoma (HCC) and improves survival. The aim of the present study is to describe the clinical, biochemical, imaging and follow-up of seven patients with HT1 and to define the consequences of the late and interrupted treatment. METHODS A retrospective study was carried out with seven HT1 patients. RESULTS The median age at onset of clinical symptoms was 11.2 months (range, 3-28 months) and the median age at diagnosis was 22 months (range, 6-58 months). Liver enzymes and coagulation parameters were back to normal in all symptomatic patients in about 2 weeks. Alfa-fetoprotein (AFP) levels were normalized within the first year of therapy. Hypoechoic nodule formation was detected in two of the seven patients despite drug treatment without an increase of AFP and any dysplastic changes in the biopsies. One patient died due to metastatic HCC because of the late diagnosis and the poor compliance of the follow-up. CONCLUSIONS This study showed once again that adherence to the treatment and a follow-up schedule of the patients are very important. Also it should not be forgotten that nodule formation can occur despite nitisinone treatment without an increase of AFP. Despite nitisinone treatment, HT1 patients still carry the risk of HCC. HCC must be detected before metastasis to other organs otherwise, patients may lose the chance for liver transplantation.
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Vora S, Chandran S, Rajadurai VS, Hussain K. Hyperinsulinemic Hypoglycemia in Infancy: Current Concepts in Diagnosis and Management. Indian Pediatr 2016; 52:1051-9. [PMID: 26713990 DOI: 10.1007/s13312-015-0772-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Molecular basis of various forms of hyperinsulinemic hypoglycemia, involving defects in key genes regulating insulin secretion, are being increasingly reported. However, the management of medically unresponsive hyperinsulinism still remains a challenge as current facilities for genetic diagnosis and appropriate imaging are limited only to very few centers in the world. We aim to provide an overview of spectrum of clinical presentation, diagnosis and management of hyperinsulinism. METHODS We searched the Cochrane library, MEDLINE and EMBASE databases, and reference lists of identified studies. CONCLUSION Analysis of blood samples, collected at the time of hypoglycemic episodes, for intermediary metabolites and hormones is critical for diagnosis and treatment. Increased awareness among clinicians about infants at-risk of hypoglycemia, and recent advances in genetic diagnosis have made remarkable contribution to the diagnosis and management of hyperinsulinism. Newer drugs like lanreotide a long acting somatostatin analogue and sirolimus (mammalian target of rapamycin (mTOR) inhibitor) appears promising as patients with diffuse disease can be treated successfully without subtotal pancreatectomy, minimizing the long-term sequelae of diabetes and pancreatic insufficiency. Newer insights in understanding the molecular and histological basis and improvements in imaging and surgical techniques will modify the approach to patients with congenital hyperinsulinism.
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Affiliation(s)
- Shrenik Vora
- Department of Neonatology, KK Womens and Childrens Hospital, Singapore; and Genetics and Epigenetics in Health and Disease Genetics and Genomic Medicine Programme, UCL Institute of Child Health, Great Ormond Street Hospital for Children, 30 Guilford Street, London, UK. Correspondence to: Dr Shrenik Vora, Senior Staff Registrar, Department of Neonatology, KK Womens and Childrens Hospital, 100, Bukit Timah Road, Singapore 229899.
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20
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Zeybek ACA, Kiykim E, Soyucen E, Cansever S, Altay S, Zubarioglu T, Erkan T, Aydin A. Hereditary tyrosinemia type 1 in Turkey: twenty year single-center experience. Pediatr Int 2015; 57:281-9. [PMID: 25223216 DOI: 10.1111/ped.12503] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 08/28/2014] [Accepted: 09/09/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hereditary tyrosinemia type 1(HT1) is a chronic disorder leading to severe hepatic, renal and peripheral nerve damage if left untreated. Despite nitisinone treatment HT1 still carries the risks of hepatocellular carcinoma (HCC) and neuropsychological outcome. METHODS A retrospective single center study was carried out based on the phenotype, therapy and outcome in 38 Turkish patients with HT1 diagnosed during the last 20 years. RESULTS None of the patients was diagnosed on newborn screening. The patients were grouped according to acute, subacute and chronic forms of the disorder. The main clinical manifestations were hepatosplenomegaly, liver and renal tubular dysfunction. Thirty-six patients were treated with nitisinone. The mean duration of nitisinone treatment was 64 months and the mean dosage was 1.2 mg/kg/day. Dietary compliance problems were frequent. Eleven patients had cognitive evaluation (mean total IQ, 84 points). Six patients had living donor liver transplantation despite nitisinone treatment: three due to suspected HCC, two for non-compliance to diet, and one for both, at a median age of 90 months. CONCLUSION Nitisinone treatment is effective and improves both short- and long-term prognosis of HT1. Early diagnosis on newborn screening is needed because delay in treatment increases the risk of the persistence of hepatic disease and HCC. Interruption of the drug can lead to re-occurrence of hepatocellular damage and neurological crisis. Increased α-fetoprotein and new hypoechoic nodule formation are the warning signs for HCC.
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Affiliation(s)
- A Cigdem Aktuglu Zeybek
- Department of Pediatrics, Division of Nutrition and Metabolism, Istanbul University, Istanbul, Turkey
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Haghighi-Kakhki H, Rezazadeh J, Ahmadi-Shadmehri A. Identification of a combined missense/splice-site mutation in FAH causing tyrosinemia type 1. J Pediatr Endocrinol Metab 2014; 27:795-8. [PMID: 24756054 DOI: 10.1515/jpem-2013-0489] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 03/06/2014] [Indexed: 11/15/2022]
Abstract
Tyrosinemia type I (HT1) is a genetic metabolic disorder characterized by progressive liver disease, kidney disease, and rickets. The disease is caused by mutations in the FAH gene that results in deficiency of fumarylacetoacetase, an enzyme that is involved in the tyrosine degradation pathway. We investigated the clinical characteristics and molecular cause of HT1 in an affected family from Iran. Molecular analysis identified a homozygous combined missense (c.G1009G>A, p.Gly337Ser) and aberrant splicing mutation removing the first 50 nucleotides of exon 12. This mutation was only described in HT1 patients from Scandinavian countries and this is the first report from another population. Although failure to thrive is one of the typical features in HT1, our proband, similar to the reported Scandinavian patients, had normal growth and development. The results of this study have applications in patient screening and genetic counselling.
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Liu G, Wei X, Chen R, Zhou H, Li X, Sun Y, Xie S, Zhu Q, Qu N, Yang G, Chu Y, Wu H, Lan Z, Wang J, Yang Y, Yi X. A novel mutation of the SLC25A13 gene in a Chinese patient with citrin deficiency detected by target next-generation sequencing. Gene 2014; 533:547-53. [DOI: 10.1016/j.gene.2013.10.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 10/06/2013] [Accepted: 10/11/2013] [Indexed: 01/29/2023]
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de Laet C, Dionisi-Vici C, Leonard JV, McKiernan P, Mitchell G, Monti L, de Baulny HO, Pintos-Morell G, Spiekerkötter U. Recommendations for the management of tyrosinaemia type 1. Orphanet J Rare Dis 2013. [DOI: 10.1186/1750-1172-8-8 10.1186/1750-1172-8-188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
The management of tyrosinaemia type 1 (HT1, fumarylacetoacetase deficiency) has been revolutionised by the introduction of nitisinone but dietary treatment remains essential and the management is not easy. In this review detailed recommendations for the management are made based on expert opinion, published case reports and investigational studies as the evidence base is limited and there are no prospective controlled studies.
The added value of this paper is that it summarises in detail current clinical knowledge about HT1 and makes recommendations for the management.
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de Laet C, Dionisi-Vici C, Leonard JV, McKiernan P, Mitchell G, Monti L, de Baulny HO, Pintos-Morell G, Spiekerkötter U. Recommendations for the management of tyrosinaemia type 1. Orphanet J Rare Dis 2013; 8:8. [PMID: 23311542 PMCID: PMC3558375 DOI: 10.1186/1750-1172-8-8] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 12/27/2012] [Indexed: 01/11/2023] Open
Abstract
The management of tyrosinaemia type 1 (HT1, fumarylacetoacetase deficiency) has been revolutionised by the introduction of nitisinone but dietary treatment remains essential and the management is not easy. In this review detailed recommendations for the management are made based on expert opinion, published case reports and investigational studies as the evidence base is limited and there are no prospective controlled studies.The added value of this paper is that it summarises in detail current clinical knowledge about HT1 and makes recommendations for the management.
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Affiliation(s)
- Corinne de Laet
- Nutrition and Metabolism Unit, Department of Pediatrics, University Children’s Hospital Queen Fabiola, Brussels, Belgium
| | - Carlo Dionisi-Vici
- Division of Metabolism, Department of Pediatric Medicine, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - James V Leonard
- UCL Institute of Child Health, 30 Guilford Street, LONDON WC1N 1EH, UK
| | - Patrick McKiernan
- The Liver Unit, Birmingham Children’s Hospital, Birmingham, B4 6NH, UK
| | - Grant Mitchell
- Pediatrics Department, CHU Sainte-Justine, 3175 Cote St Catherine, Montreal Quebec, H3T 1C5, Canada
| | - Lidia Monti
- Unit of Hepatobiliary Imaging, Department of Radiology, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | | | - Guillem Pintos-Morell
- Department of Paediatrics, Section of Paediatric Nephrology, Genetics and Metabolism, University Hospital “Germans Trias i Pujol”, Badalona. Universitat Autònoma de Barcelona, Catalonia, Spain
| | - Ute Spiekerkötter
- Ute Spiekerkoetter, Department of Pediatric and Adolescent Medicine, University Children’s Hospital, 79106, Freiburg, Germany
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Senniappan S, Shanti B, James C, Hussain K. Hyperinsulinaemic hypoglycaemia: genetic mechanisms, diagnosis and management. J Inherit Metab Dis 2012; 35:589-601. [PMID: 22231386 DOI: 10.1007/s10545-011-9441-2] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 12/06/2011] [Accepted: 12/13/2011] [Indexed: 10/14/2022]
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is due to the unregulated secretion of insulin from pancreatic β-cells. A rapid diagnosis and appropriate management of these patients is essential to prevent the potentially associated complications like epilepsy, cerebral palsy and neurological impairment. The molecular basis of HH involves defects in key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, HNF4A and UCP2) which regulate insulin secretion. The most severe forms of HH are due to loss of function mutations in ABCC8/KCNJ11 which encode the SUR1 and KIR6.2 components respectively of the pancreatic β-cell K(ATP) channel. At a histological level there are two major forms (diffuse and focal) each with a different genetic aetiology. The diffuse form is inherited in an autosomal recessive (or dominant) manner whereas the focal form is sporadic in inheritance and is localised to a small region of the pancreas. The focal form can now be accurately localised pre-operatively using a specialised positron emission tomography scan with the isotope Fluroine-18L-3, 4-dihydroxyphenyalanine (18F-DOPA-PET). Focal lesionectomy can provide cure from the hypoglycaemia. However the diffuse form is managed medically or by near total pancreatectomy (with high risk of diabetes mellitus). Recent advances in molecular genetics, imaging with 18F-DOPA-PET/CT and novel surgical techniques have changed the clinical approach to patients with HH.
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Affiliation(s)
- Senthil Senniappan
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children NHS Trust WC1N 3JH and Institute of Child Health, University College London, London, WC1N 1EH, UK
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Couce ML, Dalmau J, del Toro M, Pintos-Morell G, Aldámiz-Echevarría L. Tyrosinemia type 1 in Spain: mutational analysis, treatment and long-term outcome. Pediatr Int 2011; 53:985-9. [PMID: 21752152 DOI: 10.1111/j.1442-200x.2011.03427.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Tyrosinemia type 1 (HT1) is a rare but treatable disease. The aim of the present study was to review the efficacy of long-term treatment of HT1 with nitisinone, expand knowledge about the clinical spectrum of the disease and assess a possible genotype-phenotype correlation. METHODS A retrospective multicenter study was carried out based on questionnaires on genotype, phenotype, therapy and outcome in 34 Spanish patients with HT1. RESULTS The main manifestations that led to the diagnosis were acute liver failure (55.8%), asymptomatic hepatomegaly (44.1%) and renal tubular dysfunction (29.4%). Laboratory analysis indicated a marked increase of α-fetoprotein and coagulopathy. The most common mutation was IVS6-1(G > T; 66.6% of 24/34 patients for whom mutation analysis was available) and these patients presented less nephrocalcinosis and more hepatomegaly at diagnosis; two novel mutations (c.974C>T, c.398A>T) were found. The mean duration of treatment was 6.73 years. Dietary compliance was very good in 47.1% and good in 20.6%; nitisinone treatment adherence was very good in 85.2% of cases. Mean dose of nitisinone was 0.87 mg/kg per day with average plasma levels of 45.67 µmol/L. Only one patient required liver transplantation after nitisinone and none had hepatocellular carcinoma. CONCLUSIONS Treatment with nitisinone has improved the prognosis of HT1, and compliance is good. In Spain, screening for HT1 by plasma tyrosine and urine succinylacetone determination may be implemented with IVS6-1(G > T) mutational analysis. A correlation between low frequency of nephrocalcinosis and IVS6-1(G > T) mutation was observed.
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Affiliation(s)
- Maria Luz Couce
- Unit for Diagnosis and Treatment of Metabolic Diseases, Department of Paediatrics, University Hospital of Santiago, Santiago de Compostela, Spain.
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Kapoor RR, James C, Hussain K. Advances in the diagnosis and management of hyperinsulinemic hypoglycemia. ACTA ACUST UNITED AC 2009; 5:101-12. [PMID: 19165222 DOI: 10.1038/ncpendmet1046] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 11/12/2008] [Indexed: 12/16/2022]
Abstract
Hyperinsulinemic hypoglycemia (HH) is a consequence of unregulated insulin secretion by pancreatic beta-cells and is a major cause of hypoglycemic brain injury and mental retardation. Congenital HH is caused by mutations in genes involved in regulation of insulin secretion, seven of which have been identified (ABCC8, KCNJ11, GLUD1, CGK, HADH, SLC16A1 and HNF4A). Severe forms of congenital HH are caused by mutations in ABCC8 and KCNJ11, which encode the two components of the pancreatic beta-cell ATP-sensitive potassium channel. Mutations in HNF4A, GLUD1, CGK, and HADH lead to transient or persistent HH, whereas mutations in SLC16A1 cause exercise-induced HH. Rapid genetic analysis combined with an understanding of the histological features (focal or diffuse disease) of congenital HH and the introduction of (18)F-L-3,4-dihydroxyphenylalanine PET-CT to guide laparoscopic surgery have totally transformed the clinical approach to this complex disease. Adult-onset HH is mostly caused by an insulinoma; however, it has also been reported to present as postprandial HH in patients with noninsulinoma pancreatogenous hypoglycemia syndrome, in those who have undergone gastric-bypass surgery for morbid obesity, and in those with mutations in the insulin-receptor gene.
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Affiliation(s)
- Ritika R Kapoor
- Institute of Child Health, University College London and Great Ormond Street Hospital for Children National Health Services Trust, London, UK
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Vantyghem MC, Mention C, Dobbelaere D, Douillard C. Hypoglycémies et manifestations endocriniennes des maladies héréditaires du métabolisme chez l’adulte. ANNALES D'ENDOCRINOLOGIE 2009; 70:25-42. [DOI: 10.1016/j.ando.2008.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 12/17/2008] [Indexed: 12/20/2022]
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Santra S, Baumann U. Experience of nitisinone for the pharmacological treatment of hereditary tyrosinaemia type 1. Expert Opin Pharmacother 2008; 9:1229-36. [DOI: 10.1517/14656566.9.7.1229] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Hepatic stress in hereditary tyrosinemia type 1 (HT1) activates the AKT survival pathway in the fah-/- knockout mice model. J Hepatol 2008; 48:308-17. [PMID: 18093685 DOI: 10.1016/j.jhep.2007.09.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 09/07/2007] [Accepted: 09/12/2007] [Indexed: 02/01/2023]
Abstract
BACKGROUND/AIMS The AKT survival pathway is involved in a wide variety of human cancers. We investigated the implication of this pathway in hereditary tyrosinemia type 1 (HT1), a metabolic disease exhibiting hepatocellular carcinoma (HCC), despite treatment with 2-(2-nitro-4-trifluoromethylbenzoyl)-1,3-cyclohexadione (NTBC) which prevents liver damage. HT1 is an autosomal recessive disorder caused by accumulation of toxic metabolites due to a deficiency in fumarylacetoacetate hydrolase (FAH), the last enzyme in the catabolism of tyrosine. METHODS NTBC withdrawal in the murine fah(-/-) knockout model was used to analyze in vivo the correlation between pathophysiological, biochemical and histological features consistent with hepatocarcinogenesis and activation of the AKT survival pathway. RESULTS The HT1 stress initiated by NTBC discontinuation causes a progressive increase of liver and kidney pathophysiology. A stable activation of the AKT survival pathway is observed in the liver but not in kidneys of fah(-/-) mice. Hepatic survival is reinforced by inhibition of mitochondrial-mediated apoptosis through inactivation of Bad and induction of BCl-X(L) and BCl-2. CONCLUSIONS The chronic stress induced by liver disease in HT1 activates the AKT survival signal and inhibits intrinsic apoptosis to confer cell death resistance in vivo and favor hepatocarcinogenesis.
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Hussain K. Diagnosis and Management of Hyperinsulinaemic Hypoglycaemia of Infancy. Horm Res Paediatr 2007; 69:2-13. [PMID: 18059080 DOI: 10.1159/000111789] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Accepted: 07/27/2007] [Indexed: 11/19/2022] Open
Affiliation(s)
- Khalid Hussain
- London Centre for Paediatric Endocrinology and Metabolism, Great Ormond Street Hospital for Children NHS Trust, Institute of Child Health, University College London, London, UK.
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Baumann U, Duhme V, Auth MKH, McKiernan PJ, Holme E. Lectin-reactive alpha-fetoprotein in patients with tyrosinemia type I and hepatocellular carcinoma. J Pediatr Gastroenterol Nutr 2006; 43:77-82. [PMID: 16819381 DOI: 10.1097/01.mpg.0000228112.29359.f8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Despite the introduction of 2-(2-nitro-4-trifluormethyl-benzoyl)-1,3-cyclohexandion into the treatment of hereditary tyrosinemia type I (HT1), patients remain at risk of developing hepatocellular carcinoma (HCC). Serial total alpha-fetoprotein (AFP) levels are used to monitor the individual patient. Lectin-reactive alpha-fetoprotein (L3-AFP) is an AFP isoform that is expressed by malignant liver tumors. We investigated whether the analysis of L3-AFP could lead to earlier detection of HCC in HT1 compared with judgement based on total AFP alone. AFP electrophoresis using lectin-containing agarose gel identifies L3-AFP by the affinity of its specific carbohydrate chain to lectin. We report the retrospective analysis of sequential serum samples of 12 patients with HT1 and histologically proven HCC. AFP isoforms could be identified in all 12 patients. In 6 patients, the L3-AFP increased before the total AFP. In 3 patients, the rise in L3-AFP was parallel to the rise of total AFP; and in 3 patients, the L3-AFP was raised after the total AFP or did not increase at all. We were able to identify 6 of 12 patients with an early increase in the new tumor marker. Lectin-affinity electrophoresis may have a role in discriminating benign liver disease from HCC in HT1. We suggest the further evaluation of L3-AFP in HT1.
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Affiliation(s)
- Ulrich Baumann
- Children's Hospital, University of Essen, Essen, Germany.
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