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Yang Y, Wang X, Li M, Wang S, Wang H, Chen Q, Lu S. Identification of potential obese-specific biomarkers and pathways associated with abdominal subcutaneous fat deposition in pig using a comprehensive bioinformatics strategy. PeerJ 2024; 12:e17486. [PMID: 38832038 PMCID: PMC11146330 DOI: 10.7717/peerj.17486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 05/08/2024] [Indexed: 06/05/2024] Open
Abstract
Abdominal subcutaneous fat deposition (ASFD) is not only related to meat quality in the pig industry but also to human health in medicine. It is of great value to elucidate the potential molecular mechanisms of ASFD. The present study aims to identify obese-specific biomarkers and key pathways correlated with ASFD in pigs. The ASF-related mRNA expression dataset GSE136754 was retrieved from the Gene Expression Omnibus (GEO) database and systematically analyzed using a comprehensive bioinformatics method. A total of 565 differentially expressed genes (DEGs) were identified between three obese and three lean pigs, and these DEGs were mainly involved in the p53 signaling pathway, MAPK signaling pathway and fatty acid metabolism. A protein-protein interaction (PPI) network, consisting of 540 nodes and 1,065 edges, was constructed, and the top ten genes with the highest degree scores-ABL1, HDAC1, CDC42, HDAC2, MRPS5, MRPS10, MDM2, JUP, RPL7L1 and UQCRFS1-were identified as hub genes in the whole PPI network. Especially HDAC1, MDM2, MRPS10 and RPL7L1 were identified as potential robust obese-specific biomarkers due to their significant differences in single gene expression levels and high ROC area; this was further verified by quantitative real-time PCR (qRT-PCR) on abdominal subcutaneous fat samples from obese-type (Saba) and lean-type (Large White) pigs. Additionally, a mRNA-miRNA-lncRNA ceRNA network consisting of four potential biomarkers, 15 miRNAs and 51 lncRNAs was established, and two targeted lncRNAs with more connections, XIST and NEAT1, were identified as potentially important regulatory factors. The findings of this study may provide novel insights into the molecular mechanism involved in ASFD.
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Affiliation(s)
- Yongli Yang
- Faculty of Animal Science and Technology, Yunnan Agricuture University, Kunming, China
| | - Xiaoyi Wang
- Faculty of Animal Science and Technology, Yunnan Agricuture University, Kunming, China
| | - Mingli Li
- Faculty of Animal Science and Technology, Yunnan Agricuture University, Kunming, China
| | - Shuyan Wang
- Faculty of Animal Science and Technology, Yunnan Agricuture University, Kunming, China
| | - Huiyu Wang
- Faculty of Animal Science and Technology, Yunnan Agricuture University, Kunming, China
- Faculty of Animal Science, Xichang University, Xichang, China
| | - Qiang Chen
- Faculty of Animal Science and Technology, Yunnan Agricuture University, Kunming, China
| | - Shaoxiong Lu
- Faculty of Animal Science and Technology, Yunnan Agricuture University, Kunming, China
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2
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Lassoued N, Alaya W, Arfa S, Korbi M, Lassoued I, Amor SB, Zaouali F, Farhat Z, Chelly J, Habib Sfar M. A posteriori diagnosis of DRESS syndrome induced by diazoxide in a patient with an insulinoma: a case report and review of the literature. Front Med (Lausanne) 2023; 10:1196041. [PMID: 37601782 PMCID: PMC10436324 DOI: 10.3389/fmed.2023.1196041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
The Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome can be potentially life-threatening. The diagnosis is sometimes difficult since the clinical manifestations may be incomplete or non-specific. Insulinoma is a rare functioning neuroendocrine tumor (NET) of the pancreas. Medical therapy may be needed when surgery is contraindicated, delayed or refused. Diazoxide is widely used to control hypoglycemia in patients with insulinoma. We report a clinical case of an insulinoma in a 85-year-old patient treated with diazoxide with a fatal outcome due to a delayed diagnosis of a DRESS syndrome. This is the first case of DRESS syndrome reported after using diazoxide for insulinoma treatment in our knowledge.
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Affiliation(s)
- Najoua Lassoued
- Department of Endocrinology, Taher Sfar University Hospital, Mahdia, Tunisia
- University of Monastir, Monastir, Tunisia
| | - Wafa Alaya
- Department of Endocrinology, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Sondos Arfa
- Department of Endocrinology, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Mouna Korbi
- Department of Dermatology, Fattouma Bourguiba University Hospital, Monastir, Tunisia
| | - Ines Lassoued
- Department of Gastroenterology, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Soumaya Ben Amor
- Department of Gastroenterology, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Fatma Zaouali
- Department of Family Medicine, Faculty of Medicine of Monastir, Monastir, Tunisia
| | - Zayneb Farhat
- Department of Family Medicine, Faculty of Medicine of Monastir, Monastir, Tunisia
| | - Jihen Chelly
- Department of Infectious Disease, Taher Sfar University Hospital, Mahdia, Tunisia
| | - Mohamed Habib Sfar
- Department of Endocrinology, Taher Sfar University Hospital, Mahdia, Tunisia
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3
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Wang Z, Fu R, Han X, Wen D, Wu Y, Li S, Gu Z. Shrinking Fabrication of a Glucose-Responsive Glucagon Microneedle Patch. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2022; 9:e2203274. [PMID: 35957510 PMCID: PMC9534970 DOI: 10.1002/advs.202203274] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Indexed: 05/19/2023]
Abstract
A microdevice that offers glucagon supplements in a safe, non-invasive, and glucose-responsive manner is ideal for avoiding fatal hypoglycemia consequences from insulin overdosage during daily diabetes treatment. However, mold-assisted microfabrication of biomedical materials or devices typically needs high-resolution laser ablation to scale down structural design. In addition, the majority of the polymeric drug delivery materials being used to fabricate devices are dissolvable or deformable in aqueous environments, which restricts washing-based cleaning and purification procedures post shape fixation. This study leverages the design flexibility of 3D printing-assisted mold casting and presents a shrinking microfabrication approach that allows subsequent washing procedures to remove toxic monomer residues during polymerization. The feasibility of this approach is demonstrated by developing a glucose-responsive transdermal glucagon microneedle patch through matrix volume change-mediated release kinetic control. Shown in the type 1 diabetic mouse model, this transdermal patch can reverse the occurrence of hypoglycemia while lowering the risk of monomer residue-induced irritation during treatment. Freeing from the restrain of molding resolution for microstructure design, this shrinking methodology further provides an insight into post-fabrication purifications of biomedical materials.
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Affiliation(s)
- Zejun Wang
- Department of BioengineeringUniversity of CaliforniaLos AngelesCA90095USA
- Department of ChemistryCollege of SciencesNortheastern UniversityShenyang110819China
| | - Ruxing Fu
- Department of BioengineeringUniversity of CaliforniaLos AngelesCA90095USA
| | - Xiao Han
- Department of BioengineeringUniversity of CaliforniaLos AngelesCA90095USA
| | - Di Wen
- Department of BioengineeringUniversity of CaliforniaLos AngelesCA90095USA
| | - Yifan Wu
- Department of BioengineeringUniversity of CaliforniaLos AngelesCA90095USA
| | - Song Li
- Department of BioengineeringUniversity of CaliforniaLos AngelesCA90095USA
| | - Zhen Gu
- Department of BioengineeringUniversity of CaliforniaLos AngelesCA90095USA
- College of Pharmaceutical SciencesZhejiang UniversityHangzhou310058China
- Liangzhu LaboratoryZhejiang University Medical CenterSir Run Run Shaw HospitalHangzhou310058China
- Jinhua Institute of Zhejiang UniversityJinhua321299China
- Department of General Surgery, Sir Run Run Shaw Hospital, School of MedicineZhejiang UniversityHangzhou310016China
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4
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Fujita S, Horitani E, Miyashita Y, Fujita Y, Fukui K, Kamada Y, Mineo I, Asano Y, Iwahashi H, Kozawa J, Shimomura I. Whole-exome sequencing analysis of a Japanese patient with hyperinsulinemia and liver dysfunction. J Endocr Soc 2022; 6:bvac008. [PMID: 35187381 PMCID: PMC8852682 DOI: 10.1210/jendso/bvac008] [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: 11/16/2021] [Indexed: 11/30/2022] Open
Abstract
Hyperinsulinemia is often observed in obese subjects because of insulin resistance, but it may occur in nonobese subjects with unknown etiology. A 72-year-old man was admitted to our hospital for the examination of hyperinsulinemia, reactive hypoglycemia, and liver dysfunction. The patient’s body mass index was 23.7 kg/m2, but he had an elevated visceral fat area (125 cm2). His laboratory data showed mildly elevated liver enzymes, whereas plasma fasting glucose and serum insulin levels were 91 mg/dL and 52.3 μU/mL, respectively. In a 75-g oral glucose tolerance test, the serum insulin level reached the highest value of 1124 μU/mL at 180 minutes. There was no obvious etiology except for mild liver steatosis shown by liver biopsy. We suspected genetic abnormalities related to hyperinsulinemia. We performed whole-exome sequencing (WES) analyses and identified a heterozygous nonsense variant p.R924X in the insulin receptor (INSR) gene, a novel heterozygous missense variant p.V416M in the AKT1 gene, and a novel hemizygous missense variant p.R310Q in the PHKA2 gene, which is the causative gene of hepatic injury as glycogen storage disease type IX. It was speculated that the INSR gene variant, in addition to visceral fat accumulation, was the main cause of hyperinsulinemia and reactive hypoglycemia, and the remaining 2 variants were also partly responsible for hyperinsulinemia. WES analysis revealed candidate gene variants of hyperinsulinemia and hepatic-type glycogenosis. Thus, WES analysis may be a useful tool for clarifying the etiology when unexplained genetic pathophysiological conditions are suspected.
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Affiliation(s)
- Shingo Fujita
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Emi Horitani
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yohei Miyashita
- Department of Legal Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yukari Fujita
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
- Department of Community Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Kenji Fukui
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Yoshihiro Kamada
- Department of Advanced Metabolic Hepatology, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Ikuo Mineo
- Diabetes Center, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
| | - Yoshihiro Asano
- Department of Cardiovascular Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Hiromi Iwahashi
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
- Diabetes Center, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
- Department of Diabetes Care Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Junji Kozawa
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
- Department of Diabetes Care Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, 2-2-B5 Yamada-oka, Suita, Osaka, 565-0871, Japan
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Yasuda A, Seki T, Kitajima N, Baba T, Sasaki N, Kametani Y, Seki M, Tanaka K, Oki M. A case of insulinoma effectively treated with low‐dose diazoxide. Clin Case Rep 2020; 8:1884-1889. [PMID: 33088512 PMCID: PMC7562850 DOI: 10.1002/ccr3.3017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/13/2020] [Accepted: 05/16/2020] [Indexed: 12/15/2022] Open
Abstract
Diazoxide is a benzothiadiazine that can be effective in managing hypoglycemia in frail patients with surgical risk. We report here a case of insulinoma effectively treated with diazoxide, as our report will be helpful for similar cases.
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Affiliation(s)
- Atsushi Yasuda
- Division of Nephrology, Endocrinology and Metabolism Department of Internal Medicine Tokai University School of Medicine Kanagawa Japan
| | - Toshiro Seki
- Division of Nephrology, Endocrinology and Metabolism Department of Internal Medicine Tokai University School of Medicine Kanagawa Japan
| | - Natsumi Kitajima
- Division of Nephrology, Endocrinology and Metabolism Department of Internal Medicine Tokai University School of Medicine Kanagawa Japan
| | - Tanefumi Baba
- Department of Neurosurgery Tokai University School of Medicine Kanagawa Japan
| | - Noriko Sasaki
- Division of Rheumatology Department of Internal Medicine Tokai University School of Medicine Kanagawa Japan
| | - Yoshie Kametani
- Department of Molecular Life Science Division of Basic Medical Science Tokai University School of Medicine Kanagawa Japan
| | | | - Kazuko Tanaka
- Division of General Internal Medicine Department of Internal Medicine Tokai University School of Medicine Kanagawa Japan
| | - Masayuki Oki
- Division of General Internal Medicine Department of Internal Medicine Tokai University School of Medicine Kanagawa Japan
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6
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Hasbaoui BE, Elyajouri A, Abilkassem R, Agadr A. Congenital hyperinsulinsim: case report and review of literature. Pan Afr Med J 2020; 35:53. [PMID: 32537058 PMCID: PMC7250230 DOI: 10.11604/pamj.2020.35.53.16604] [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] [Received: 07/19/2018] [Accepted: 06/29/2019] [Indexed: 11/11/2022] Open
Abstract
Neonatal hypoglycemia (NH) is one of the most common abnormalities encountered in the newborn. Hypoglycemia continues to be an important cause of morbidity in neonates and children. Prompt diagnosis and management of the underlying hypoglycemia disorder is critical for preventing brain damage and improving outcomes. Congenital hyperinsulinism (CHI) is the most common and severe cause of persistent hypoglycemia in neonates and children, it represents a group of clinically, genetically and morphologically heterogeneous disorders characterised by dysregulation of insulin secretion from pancreatic β-cells. It is extremely important to recognize this condition early and institute appropriate management to prevent significant brain injury leading to complications like epilepsy, cerebral palsy and neurological impairment. Histologically, CHI is divided mainly into two types focal and diffuse disease. The diffuse form is inherited in an autosomal recessive (or dominant) manner whereas the focal form is sporadic in inheritance and is localized to a small region of the pancreas. Recent discoveries of the genetic causes of CHI have improved our understanding of the pathophysiology, but its management is complex and requires the integration of clinical, biochemical, molecular, and imaging findings to establish the appropriate treatment according to the subtype. Here we present a case of sever congenital hyperinsulinism in a girl admitted for lethargy, irritability and general seizures accompanied with profound hypoglycemia, in spite of aggressive medical treatment, she died because of sever congenital hyperinsulinism diazoxide unresponsive.
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Affiliation(s)
- Brahim El Hasbaoui
- Department of pediatrics, Military Teaching Hospital Mohammed V, Faculty of Medicine and Pharmacy, University Mohammed V, Rabat, Morocco
| | - Abdelhkim Elyajouri
- Department of pediatrics, Military Teaching Hospital Mohammed V, Faculty of Medicine and Pharmacy, University Mohammed V, Rabat, Morocco
| | - Rachid Abilkassem
- Department of pediatrics, Military Teaching Hospital Mohammed V, Faculty of Medicine and Pharmacy, University Mohammed V, Rabat, Morocco
| | - Aomar Agadr
- Department of pediatrics, Military Teaching Hospital Mohammed V, Faculty of Medicine and Pharmacy, University Mohammed V, Rabat, Morocco
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7
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Kallem VR, Pandita A, Gupta G. Hypoglycemia: When to Treat? Clin Med Insights Pediatr 2017; 11:1179556517748913. [PMID: 29276423 PMCID: PMC5734558 DOI: 10.1177/1179556517748913] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 11/26/2017] [Indexed: 11/16/2022] Open
Abstract
Hypoglycemia is the most common metabolic disorder encountered in neonates. The definition of hypoglycemia as well as its clinical significance and management remain controversial. Most cases of neonatal hypoglycemia are transient, respond readily to treatment, and are associated with an excellent prognosis. Persistent hypoglycemia is more likely to be associated with abnormal endocrine conditions, such as hyperinsulinemia, as well as possible neurologic sequelae. Manifestations of hypoglycemia include seizures which can result in noteworthy neuromorbidity in the long haul. Thus, hypoglycemia constitutes a neonatal emergency which requires earnest analytic assessment and prompt treatment. In this review, we have tried to cover the pathophysiology, the screening protocol for high-risk babies, management, long-term neurologic sequelae associated with neonatal hypoglycemia, with evidence-based answers wherever possible, and our own practices.
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Affiliation(s)
| | - Aakash Pandita
- Department of Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Girish Gupta
- Department of Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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John CM, Agarwal P, Govindarajulu S, Sundaram S, Senniappan S. Congenital hyperinsulinism: diagnostic and management challenges in a developing country - case report. Ann Pediatr Endocrinol Metab 2017; 22:272-275. [PMID: 29301189 PMCID: PMC5769830 DOI: 10.6065/apem.2017.22.4.272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 04/06/2017] [Accepted: 04/21/2017] [Indexed: 11/30/2022] Open
Abstract
Management of congenital hyperinsulinemia of infancy (CHI) is challenging. A 4-month-old female infant with persistent hypoglycemia and elevated insulin levels was diagnosed with CHI. Gallium-68 DOTANOC positron emission tomography/computed tomography (PET/CT) scan (68Ga-labeled [1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic acid]-1-NaI3-octreotide) demonstrated focal disease in the body of the pancreas. Genetic studies indicated paternal inheritance, making focal disease likely. She was started on diazoxide therapy with partial improvement in blood glucose levels. Due to a suboptimal response to diazoxide and the likelihood of focal disease amenable to surgery, a laparoscopic subtotal pancreatectomy with preservation of the head of the pancreas was performed. The biopsy demonstrated diffuse hyperplastic pancreatic islet cells on immunohistochemistry, indicative of diffuse rather than focal disease. Paternal inheritance is a recognized indicator of focal disease. Gallium-68 DOTANOC PET/CT scan is the only available imaging modality in South India as 18F-L-dihydroxyphenylalanine (DOPA) PET/CT scan is not available at present. A laparoscopic approach reduces the postoperative recovery time and morbidity in such patients. The absence of 18F-L-DOPA PET/CT scan and the limited supply of diazoxide makes the management of this complex condition more challenging in developing countries.
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Affiliation(s)
- Cheri Mathews John
- Angels Speciality Clinic, Chennai, India,Address for correspondence: Cheri Mathews John, DCH, FRCPCHhttps://orcid.org/0000-0003-3066-7423 Angels Speciality Clinic, AL-190, 1st street, 12th Main Road, Anna Nagar, Chennai 600040, India Tel: +91-9840362658 Fax: +91-9840362658 E-mail:
| | - Prakash Agarwal
- Department of Paediatric Surgery, Sri Ramachandra University, Chennai, India
| | | | - Sandhya Sundaram
- Department of Pathology, Sri Ramachandra University, Chennai, India
| | - Senthil Senniappan
- Department of Paediatric Endocrinology, Alder Hey Children’s Hospital, Liverpool, UK
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Demirbilek H, Rahman SA, Buyukyilmaz GG, Hussain K. Diagnosis and treatment of hyperinsulinaemic hypoglycaemia and its implications for paediatric endocrinology. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2017; 2017:9. [PMID: 28855921 PMCID: PMC5575922 DOI: 10.1186/s13633-017-0048-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/15/2017] [Indexed: 12/14/2022]
Abstract
Glucose homeostasis requires appropriate and synchronous coordination of metabolic events and hormonal activities to keep plasma glucose concentrations in a narrow range of 3.5–5.5 mmol/L. Insulin, the only glucose lowering hormone secreted from pancreatic β-cells, plays the key role in glucose homeostasis. Insulin release from pancreatic β-cells is mainly regulated by intracellular ATP-generating metabolic pathways. Hyperinsulinaemic hypoglycaemia (HH), the most common cause of severe and persistent hypoglycaemia in neonates and children, is the inappropriate secretion of insulin which occurs despite low plasma glucose levels leading to severe and persistent hypoketotic hypoglycaemia. Mutations in 12 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1 and PMM2) constitute the underlying molecular mechanisms of congenital HH. Since insulin supressess ketogenesis, the alternative energy source to the brain, a prompt diagnosis and immediate management of HH is essential to avoid irreversible hypoglycaemic brain damage in children. Advances in molecular genetics, imaging methods (18F–DOPA PET-CT), medical therapy and surgical approach (laparoscopic and open pancreatectomy) have changed the management and improved the outcome of patients with HH. This up to date review article provides a background to the diagnosis, molecular genetics, recent advances and therapeutic options in the field of HH in children.
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Affiliation(s)
- Huseyin Demirbilek
- Department of Paediatric Endocrinology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Sofia A Rahman
- Great Ormond Street Institute of Child Health, Genetics and Genomic Medicine, University College London, 30 Guilford Street, London, WC1N 1EH UK
| | - Gonul Gulal Buyukyilmaz
- Department of Paediatric Endocrinology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Khalid Hussain
- Department of Paediatric Medicine Sidra Medical & Research Center, OPC, C6-337, PO Box 26999, Doha, Qatar
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Maiorana A, Dionisi-Vici C. Hyperinsulinemic hypoglycemia: clinical, molecular and therapeutical novelties. J Inherit Metab Dis 2017; 40:531-542. [PMID: 28656511 DOI: 10.1007/s10545-017-0059-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/25/2017] [Accepted: 05/29/2017] [Indexed: 01/01/2023]
Abstract
Hyperinsulinemic hypoglycemia (HI) is the most common cause of hypoglycemia in children. Impairment of cellular pathways involved in insulin secretion from pancreatic β-cells, broadly classified as channelopathies and metabolopathies, have been discovered in the past two decades. The increasing use of NGS target panels, combined with clinical, biochemical and imaging findings allows differentiating the diagnostic management of children with focal forms, surgically curable, from those with diffuse forms, more conservatively treated with pharmacological and nutritional interventions. Specific approaches according to the subtype of HI have been established and novel therapies are currently under investigation. Despite diagnostic and therapeutic advances, HI remains an important cause of morbidity in children, still accounting for 26-44% of permanent intellectual disabilities, especially in neonatal-onset patients. Initial insult from recurrent hypoglycemia in early life greatly contributes to the poor outcomes. Therefore, patients need to be rapidly identified and treated aggressively, and require at follow-up a complex and regular monitoring, managed by a multidisciplinary HI team. This review gives an overview on the more recent diagnostic and therapeutic tools, on the novel drug and nutritional therapies, and on the long-term neurological outcomes.
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Affiliation(s)
- Arianna Maiorana
- Division of Metabolic Diseases, Department of Pediatric Specialties, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - Carlo Dionisi-Vici
- Division of Metabolic Diseases, Department of Pediatric Specialties, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
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Incidence and Predictive Factors of Postprandial Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass: A Five year Longitudinal Study. Ann Surg 2017; 264:878-885. [PMID: 27560624 DOI: 10.1097/sla.0000000000001915] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Postprandial hyperinsulinemic hypoglycemia (PHH) is often reported after Roux-en-Y gastric bypass (RYGB). In the absence of a prospective study, the clinical and biological determinants of PHH remain unclear. OBJECTIVE To determine the incidence and predictive factors of PHH after RYGB. METHODS Participants were 957 RYGB patients enrolled in an ongoing longitudinal cohort study. We analyzed the results of an oral glucose tolerance test (OGTT) routinely performed before surgery and 1 and/or 5 years after. PHH was defined as blood glucose < 50 mg/dL AND plasma insulin > 3 mU/L at 120 minutes post glucose challenge. Validated indices of insulin sensitivity (Matsuda index), beta-cell function (Insulinogenic index), and beta-cell mass (fasting C-peptide: glucose ratio) were calculated, from glucose, insulin, and c-peptide values measured during OGTT. RESULTS OGTT results were available in all patients at baseline, in 85.6% at 12 months and 52.8% at 60 months. The incidence of PHH was 0.5% at baseline, 9.1% * and 7.9%* at 12 months and 60 months following RYGB (*: P < 0.001). In multivariate logistic regression analysis, PHH after RYGB was independently associated with lower age (P = 0.005), greater weight loss (P = 0.031), as well as higher beta-cell function (P = 0.002) and insulin sensitivity (P < 0.001), but not with beta-cell mass (P = 0.381). A preoperative elevated beta-cell function was an independent predictor of PHH after RYGB (receiver operating characteristics curve area under the curve 0.68, P = 0.04). CONCLUSIONS: The incidence of PHH significantly increased after RYGB but remained stable between 1 and 5 years. The estimation of beta-cell function with an OGTT before surgery can identify patients at risk for developing PHH after RYGB.
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Davi MV, Pia A, Guarnotta V, Pizza G, Colao A, Faggiano A. The treatment of hyperinsulinemic hypoglycaemia in adults: an update. J Endocrinol Invest 2017; 40:9-20. [PMID: 27624297 DOI: 10.1007/s40618-016-0536-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Treatment of hyperinsulinemic hypoglycaemia (HH) is challenging due to the rarity of this condition and the difficulty of differential diagnosis. The aim of this article is to give an overview of the recent literature on the management of adult HH. METHODS A search for reviews, original articles, original case reports between 1995 and 2016 in PubMed using the following keywords: hyperinsulinemic hypoglycaemia, insulinoma, nesidioblastosis, gastric bypass, autoimmune hypoglycaemia, hyperinsulinism, treatment was performed. RESULTS One hundred and forty articles were selected and analysed focusing on the most recent treatments of HH. CONCLUSIONS New approaches to treatment of HH are available including mini-invasive surgical techniques and alternative local-regional ablative therapy for benign insulinoma and everolimus for malignant insulinoma. A correct differential diagnosis is of paramount importance to avoid unnecessary surgical operations and to implement the appropriate treatment mainly in the uncommon forms of HH, such as nesidioblastosis and autoimmune hypoglycaemia.
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Affiliation(s)
- M V Davi
- Section of Endocrinology, Medicina Generale e Malattie Aterotrombotiche e Degenerative, Department of Medicine, University of Verona, Piazzale LA Scuro, Policlinico G.B. Rossi, 37134, Verona, Italy.
| | - A Pia
- Internal Medicine I, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Italy
| | - V Guarnotta
- Section of Endocrinology, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Palermo, Italy
| | - G Pizza
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Colao
- Endocrinology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - A Faggiano
- Thyroid and Parathyroid Surgery Unit, Istituto Nazionale per lo Studio e la Cura dei Tumori "Fondazione G. Pascale" IRCCS, Naples, Italy
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Pan S, Zhang M, Li Y. Experience of Octreotide Therapy for Hyperinsulinemic Hypoglycemia in Neonates Born Small for Gestational Age: A Case Series. Horm Res Paediatr 2016; 84:383-7. [PMID: 26448570 DOI: 10.1159/000441108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 09/15/2015] [Indexed: 11/19/2022] Open
Abstract
AIMS Hyperinsulinemic hypoglycemia (HH) is common in small-for-gestational-age (SGA) neonates. Diazoxide is often used as the first-line medication for HH in SGA neonates. Unfortunately, diazoxide is not authorized in China. We examined the effectiveness of octreotide as an alternative therapy to treat HH in SGA neonates. There is limited data on the use of octreotide in HH of SGA neonates. METHODS Seven SGA neonates with HH who were admitted to the Department of Neonatology at the Third Affiliated Hospital of Sun Yat-sen University between January 2013 and December 2014 received octreotide at an initial dose of 5 μg/kg/day through subcutaneous injection at 8-hour intervals. Depending on the glycemic control, the dose of octreotide was increased in increments of 2-5 μg/kg/day every 3-5 days to the maximum dose of 30 μg/kg/day. RESULTS The age of neonates with HH diagnosis ranged from 1 to 4 days. The maximum dose of octreotide ranged from 8 to 18 μg/kg/day. The duration of octreotide therapy ranged from 9 to 45 days. All patients had a clear glycemic response to octreotide, and no major adverse events were observed during the treatment. CONCLUSIONS Octreotide may be a useful alternative therapy in HH of SGA neonates when diazoxide is unavailable.
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Affiliation(s)
- Sinian Pan
- Department of Neonatology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Warncke K, Falco F, Rabl W, Engelsberger I, Saier J, Flores-Rodriguez D, Burdach S, Bonfig W. Genetic characteristics and long-term follow-up of 11 patients with congenital hyperinsulinism followed in a single center. J Pediatr Endocrinol Metab 2016; 29:1187-1194. [PMID: 27682711 DOI: 10.1515/jpem-2016-0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 08/29/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) is a rare disease with an estimated incidence of 1:40,000 live births. Here, we characterize 11 patients treated at Munich Children's Hospital Schwabing. METHODS We analyzed data on birth, treatment and laboratory results including genetic testing and evaluated the long-term course with a follow-up visit. RESULTS All patients had severe, diazoxide-(DZX)-resistant hypoglycemia, beginning immediately after birth. Two patients were treated by medical therapy, eight underwent subtotal pancreatectomy and one had a partial resection. Both patients who had medical therapy still suffer from occasional hypoglycemia. Six patients with subtotal pancreatectomy were affected by mild hypoglycemia. Seventy-five percent of patients who had surgical treatment developed diabetes mellitus (DM) at a median age of 10.5 (8-13) years. In 89% of patients with available genetic testing, mutations of the ABCC8 gene were detected. CONCLUSIONS The majority of CHI-patients not responding to DZX underwent surgery. After subtotal pancreatectomy, patients typically developed diabetes around early puberty.
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Nannipieri M, Belligoli A, Guarino D, Busetto L, Moriconi D, Fabris R, Mari A, Baldi S, Anselmino M, Foletto M, Vettor R, Ferrannini E. Risk Factors for Spontaneously Self-Reported Postprandial Hypoglycemia After Bariatric Surgery. J Clin Endocrinol Metab 2016; 101:3600-3607. [PMID: 27336358 DOI: 10.1210/jc.2016-1143] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
CONTEXT Postprandial hypoglycemia (PPHG) is a recognized complication of Roux-en-Y gastric bypass (RYGB) surgery. Data on PPHG after laparoscopic sleeve gastrectomy (LSG) are scant. OBJECTIVE The objective of the study was to identify preoperative predictors of PPHG in subjects spontaneously self-reporting PPHG after RYGB or LSG. Patients, Setting, and Intervention: Nondiabetic patients spontaneously self-reporting symptoms/signs of PPHG (PPHG group, 21 RYGB and 11 LSG) were compared in a case-control design with subjects who never experienced spontaneous or oral glucose tolerance test (OGTT)-induced hypoglycemia over 24 months after surgery (No-PPHG group, 13 RYGB and 40 LSG). Paired pre- and postoperative 3-hour OGTTs were analyzed in all participants. MAIN OUTCOME MEASURES Insulin sensitivity was assessed by the oral glucose insulin sensitivity index and β-cell function by mathematical modeling of the C-peptide response to glucose. RESULTS Before surgery, the body mass index was lower in PPHG than No-PPHG patients in the RYGB (P = .002) and trended similarly in the LSG group (P = .08). Fasting glycemia and the glucose-OGTT nadir were lower in the PPHG than the No-PPHG subjects in both surgery groups. Before surgery, insulin sensitivity was higher in PPHG than No-PPHG in the RYGB (393 ± 55 vs 325 ± 44 mL/min-1 · m-2, P = .001) and LSG groups (380 ± 48 vs 339 ± 60 mL/min-1 · m-2, P = .05) and improved to a similar extent in all groups after surgery. Before surgery, β-cell glucose sensitivity was higher in PPHG than No-PPHG in both RYGB (118 ± 67 vs 65 ± 24 pmol/min-1 · m2 · mM-1) and LSG patients (114 ± 32 vs 86 ± 33) (both P = .02) and improved in all subjects after surgery. CONCLUSIONS In subjects self-reporting PPHG after surgery, lower presurgery plasma glucose concentrations, higher insulin sensitivity, and better β-cell glucose sensitivity are significant predictors of PPHG after both RYGB and LSG.
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Affiliation(s)
- Monica Nannipieri
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Anna Belligoli
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Daniela Guarino
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Luca Busetto
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Diego Moriconi
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Roberto Fabris
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Andrea Mari
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Simona Baldi
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Marco Anselmino
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Mirto Foletto
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Roberto Vettor
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
| | - Ele Ferrannini
- Department of Clinical and Experimental Medicine (M.N., D.G., D.M., S.B.), University of Pisa, 56126 Pisa, Italy; Departments of Medicine (A.B., L.B., R.F., R.V.) and Oncology and Surgery Science (M.F.), University of Padua, 35122 Padua, Italy; National Research Council Institute of Neurosciences (A.M.), Padua, Italy; Bariatric Surgery Unit (M.A.), Santa Chiara Hospital, 56100 Pisa, Italy; National Research Council Institute of Clinical Physiology (E.F.), 56124 Pisa, Italy
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Shah P, Rahman SA, McElroy S, Gilbert C, Morgan K, Hinchey L, Senniappan S, Levy H, Amin R, Hussain K. Use of Long-Acting Somatostatin Analogue (Lanreotide) in an Adolescent with Diazoxide-Responsive Congenital Hyperinsulinism and Its Psychological Impact. Horm Res Paediatr 2016; 84:355-60. [PMID: 26375451 DOI: 10.1159/000439131] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/31/2015] [Indexed: 11/19/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a common cause of hypoglycaemia due to unregulated insulin secretion from pancreatic β cells. Medical management includes use of oral diazoxide (a KATP channel agonist) and daily injectable octreotide (somatostatin analogue) therapy. However, diazoxide is associated with severe sideeffects such as coarse facies, hypertrichosis and psychosocial/compliance issues in adolescents. Lanreotide (a long-acting somatostatin analogue) is used in adults with neuroendocrine tumours; however, its role in patients with CHI has not been well described. A 15-year-old girl with diazoxide-responsive CHI had severe hypertrichosis secondary to diazoxide and subsequent compliance/psychosocial issues. She was commenced on 30 mg of lanreotide every 4 weeks as a deep subcutaneous injection, in an attempt to address these issues. She was able to come off diazoxide treatment 2 months after starting lanreotide. Presently, after 2.5 years of lanreotide treatment, her blood glucose control is stable with complete resolution of hypertrichosis. Clinically significant improvements in the self-reported Paediatric Quality of Life (PedsQL) questionnaire and Strengths and Difficulties Questionnaire (SDQ) were reported after 1 year on lanreotide. No side effects were found, and her liver/thyroid function and abdominal ultrasound have been normal. We report the first case on the use of lanreotide in an adolescent girl with diazoxide-responsive CHI with significant improvement of quality of life.
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Affiliation(s)
- Pratik Shah
- Developmental Endocrinology Research Group, Genetics and Genomic Medicine Programme, Institute of Child Health, University College London, London, UK
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Molven A, Hollister-Lock J, Hu J, Martinez R, Njølstad PR, Liew CW, Weir G, Kulkarni RN. The Hypoglycemic Phenotype Is Islet Cell-Autonomous in Short-Chain Hydroxyacyl-CoA Dehydrogenase-Deficient Mice. Diabetes 2016; 65:1672-8. [PMID: 26953163 PMCID: PMC4878426 DOI: 10.2337/db15-1475] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 03/04/2016] [Indexed: 11/30/2022]
Abstract
Congenital hyperinsulinism of infancy (CHI) can be caused by inactivating mutations in the gene encoding short-chain 3-hydroxyacyl-CoA dehydrogenase (SCHAD), a ubiquitously expressed enzyme involved in fatty acid oxidation. The hypersecretion of insulin may be explained by a loss of interaction between SCHAD and glutamate dehydrogenase in the pancreatic β-cells. However, there is also a general accumulation of metabolites specific for the enzymatic defect in affected individuals. It remains to be explored whether hypoglycemia in SCHAD CHI can be uncoupled from the systemic effect on fatty acid oxidation. We therefore transplanted islets from global SCHAD knockout (SCHADKO) mice into mice with streptozotocin-induced diabetes. After transplantation, SCHADKO islet recipients exhibited significantly lower random and fasting blood glucose compared with mice transplanted with normal islets or nondiabetic, nontransplanted controls. Furthermore, intraperitoneal glucose tolerance was improved in animals receiving SCHADKO islets compared with those receiving normal islets. Graft β-cell proliferation and apoptosis rates were similar in the two transplantation groups. We conclude that hypoglycemia in SCHAD-CHI is islet cell-autonomous.
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Affiliation(s)
- Anders Molven
- Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Stem Cell Institute, Harvard Medical School, Boston, MA Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Bergen, Norway KG Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Jennifer Hollister-Lock
- Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Stem Cell Institute, Harvard Medical School, Boston, MA
| | - Jiang Hu
- Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Stem Cell Institute, Harvard Medical School, Boston, MA
| | - Rachael Martinez
- Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Stem Cell Institute, Harvard Medical School, Boston, MA
| | - Pål R Njølstad
- KG Jebsen Center for Diabetes Research, Department of Clinical Science, University of Bergen, Bergen, Norway Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Chong Wee Liew
- Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Stem Cell Institute, Harvard Medical School, Boston, MA Department of Physiology and Biophysics, University of Illinois at Chicago, Chicago, IL
| | - Gordon Weir
- Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Stem Cell Institute, Harvard Medical School, Boston, MA
| | - Rohit N Kulkarni
- Islet Cell and Regenerative Biology, Joslin Diabetes Center, Harvard Stem Cell Institute, Harvard Medical School, Boston, MA Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA Harvard Stem Cell Institute, Boston, MA
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18
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Lee CT, Liu SY, Tung YC, Chiu PC, Wu MZ, Tsai WY. Clinical characteristics and long-term outcome of Taiwanese children with congenital hyperinsulinism. J Formos Med Assoc 2016; 115:306-10. [DOI: 10.1016/j.jfma.2015.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 03/28/2015] [Accepted: 04/05/2015] [Indexed: 10/23/2022] Open
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Abstract
Various bariatric surgical procedures are effective at improving health in patients with obesity associated co-morbidities, but the aim of this review is to specifically describe the mechanisms through which Roux-en-Y gastric bypass (RYGB) surgery enables weight loss for obese patients using observations from both human and animal studies. Perhaps most but not all clinicians would agree that the beneficial effects outweigh the harm of RYGB; however, the mechanisms for both the beneficial and deleterious (for example postprandial hypoglycaemia, vitamin deficiency and bone loss) effects are ill understood. The exaggerated release of the satiety gut hormones, such as GLP-1 and PYY, with their central and peripheral effects on food intake has given new insight into the physiological changes that happen after surgery. The initial enthusiasm after the discovery of the role of the gut hormones following RYGB may need to be tempered as the magnitude of the effects of these hormonal responses on weight loss may have been overestimated. The physiological changes after RYGB are unlikely to be due to a single hormone, or single mechanism, but most likely involve complex gut-brain signalling. Understanding the mechanisms involved with the beneficial and deleterious effects of RYGB will speed up the development of effective, cheaper and safer surgical and non-surgical treatments for obesity.
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Affiliation(s)
- G Abdeen
- Investigative Science, Imperial College London, London, UK.
| | - C W le Roux
- Investigative Science, Imperial College London, London, UK
- Diabetes Complications Research Centre, Conway Institute, University College Dublin, Dublin, Ireland
- Gastrosurgical Laboratory, University of Gothenburg, Gothenburg, Sweden
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20
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Komatsu Y, Nakamura A, Takihata M, Inoue Y, Yahagi S, Tajima K, Tsuchiya H, Takano T, Yamakawa T, Yoshida M, Miyoshi H, Terauchi Y. Safety and tolerability of diazoxide in Japanese patients with hyperinsulinemic hypoglycemia. Endocr J 2016; 63:311-4. [PMID: 26598136 DOI: 10.1507/endocrj.ej15-0428] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Diazoxide is a non-diuretic benzothiadiazine derivative, one of a group of substances introduced into clinical practice in the 1950s for the treatment of hypertension. Fajans reported the use of diazoxide for the treatment of insulinoma in 1979. Although patients with hyperinsulinemic hypoglycemia worldwide have been treated with diazoxide for more than 30 years, there are no recent reports about the adverse effects of this drug in Asian patients, including Japanese patients. Herein, we report the results of our retrospective clinical record review of 6 Japanese patients (3 females and 3 males, ranging in age from 58 to 91 years) with hyperinsulinemic hypoglycemia and inoperable insulinoma treated with diazoxide. Diazoxide improved control of hypoglycemic symptoms and maintained normoglycemia in 5 of the 6 patients, and was ineffective in one patient. Surprisingly, although all 6 patients received diazoxide according to the treatment strategy recommended in Western patients, 5 of the 6 patients developed edema and two developed congestive heart failure. Thus, when starting treatment with diazoxide in Japanese patients, the symptoms and signs of fluid retention should be evaluated carefully. Also, appropriate protocols for treatment with diazoxide should be evaluated by means of clinical trials in Japanese patients with hyperinsulinemic hypoglycemia.
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Affiliation(s)
- Yumiko Komatsu
- Department of Endocrinology and Metabolism, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Thompson SM, Vella A, Thompson GB, Rumilla KM, Service FJ, Grant CS, Andrews JC. Selective Arterial Calcium Stimulation With Hepatic Venous Sampling Differentiates Insulinoma From Nesidioblastosis. J Clin Endocrinol Metab 2015; 100:4189-97. [PMID: 26312578 PMCID: PMC4702445 DOI: 10.1210/jc.2015-2404] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
CONTEXT In adult patients with endogenous hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging, insulinoma and non-insulinoma pancreatogenous hypoglycemic syndrome (NIPHS) resulting from diffuse nesidioblastosis must be considered in the differential diagnosis. It is not known whether the biochemical results of selective arterial calcium stimulation (SACST) with hepatic venous sampling can differentiate insulinoma from diffuse nesidioblastosis. OBJECTIVE To determine the specificity of SACST with hepatic venous sampling in differentiating insulinoma from diffuse nesidioblastosis. DESIGN Retrospective review (January 1996 to March 2014). SETTING Tertiary referral center. PATIENTS OR OTHER PARTICIPANTS A total of 116 patients with biochemical evidence of endogenous hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging who were subsequently shown at surgery to have insulinoma (n = 42) or nesidioblastosis (n = 74) after undergoing SACST with hepatic venous sampling. INTERVENTION(S) SACST with hepatic venous sampling before pancreatic exploration. MAIN OUTCOME MEASURE(S) Receiver operating characteristic curves were generated from the biochemical results of SACST to determine the specificity of the maximum hepatic venous insulin concentration (mHVI) and the relative-fold increase in hepatic venous insulin concentration (rHVI) over baseline after calcium injection from the dominant artery in differentiating insulinoma from nesidioblastosis. RESULTS The mHVI (21.5-fold; P < .001) and rHVI (3.9-fold; P < .001) were significantly higher in the insulinoma group compared to the nesidioblastosis group. The areas under the receiver operating characteristic curve for mHVI and rHVI were excellent (0.94; P < .0001) and good (0.83; P < .0001), respectively, for differentiating insulinoma from nesidioblastosis. mHVI cutoffs of > 91.5 and > 263.5 μIU/mL were 95 and 100% specific for insulinoma, respectively. A 19-fold increase in rHVI over baseline was 99% specific for insulinoma. CONCLUSIONS These data suggest that the mHVI and rHVI at SACST may be useful in differentiating insulinoma from nesidioblastosis with high specificity in patients with hyperinsulinemic hypoglycemia and negative or inconclusive noninvasive imaging.
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Affiliation(s)
- Scott M Thompson
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Adrian Vella
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Geoffrey B Thompson
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Kandelaria M Rumilla
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - F John Service
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - Clive S Grant
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
| | - James C Andrews
- Department of Radiology (S.M.T., J.C.A.), Department of Surgery (S.M.T., G.B.T., C.S.G.), Division of Endocrinology, Diabetes, and Metabolism (A.V., F.J.S.), and Department of Laboratory Medicine and Pathology (K.M.R.), College of Medicine, Mayo Clinic, Rochester, Minnesota 55905
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Conwell LS, Greer RM, Neville KA, Amato LA, Campbell L, Fiumara F. (18) Fluoro-dihydroxy phenylalanine positron emission tomography/computed tomography scanning for congenital hyperinsulinism of infancy. J Paediatr Child Health 2015; 51:826-9. [PMID: 25622923 DOI: 10.1111/jpc.12827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Louise S Conwell
- Department of Endocrinology and Diabetes, Royal Children's Hospital, Brisbane, Queensland.,Queensland Children's Medical Research Institute, University of Queensland, Brisbane, Queensland.,School of Medicine, University of Queensland, Brisbane, Queensland
| | - Ristan M Greer
- Queensland Children's Medical Research Institute, University of Queensland, Brisbane, Queensland
| | - Kristen A Neville
- Department of Endocrinology, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of NSW, Sydney, New South Wales, Australia
| | - Lisa A Amato
- Department of Endocrinology, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women's and Children's Health, Faculty of Medicine, University of NSW, Sydney, New South Wales, Australia
| | - Louise Campbell
- Department of Nuclear Medicine and Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland
| | - Frank Fiumara
- Department of Nuclear Medicine and Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland
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23
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Kuroda Y, Iwahashi H, Mineo I, Fukui K, Fukuhara A, Iwamoto R, Imagawa A, Shimomura I. Hyperinsulinemic hypoglycemia syndrome associated with mutations in the human insulin receptor gene: report of two cases. Endocr J 2015; 62:353-62. [PMID: 25753915 DOI: 10.1507/endocrj.ej14-0547] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Insulinoma and insulin or insulin receptor (IR) autoantibodies are the main causes of hyperinsulinemic hypoglycemia in adults, but the exact cause in other cases remains obscure. This study is to determine the genetic basis of hyperinsulinemic hypoglycemia in two cases without the above abnormalities. Sequence analysis of IR gene in two patients with adult-onset hyperinsulinemic hypoglycemia and their relatives were performed, and the mutant gene observed in one case was analyzed. Both cases had normal levels of fasting plasma glucose (FPG), fasting hyperinsulinemia, low insulin sensitivity, and hypoglycemia with excessive insulin secretion during oral glucose tolerance test (OGTT). Both reported adult-onset postprandial hypoglycemic symptoms. In one patient, a missense mutation (Arg256Cys) was detected in both alleles of the IR gene, and his parents had the same mutation in only one allele but no hypoglycemia. The other had a novel nonsense mutation (Trp1273X) followed by a mutation (Gln1274Lys) in one allele, and his 9-year old son had the same mutation in one allele, together with hyperinsulinemic hypoglycemia during OGTT. Overexpression experiments of the mutant gene found in Case 1 in mammalian cells showed abnormal processing of the IR protein and demonstrated reduced function of Akt/Erk phosphorylation by insulin in the cells. In two cases of hyperinsulinemic hypoglycemia in adults, we found novel mutations in IR gene considered to be linked to hypoglycemia. We propose a disease entity of adult-onset hyperinsulinemic hypoglycemia syndrome associated with mutations in IR gene.
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Affiliation(s)
- Yohei Kuroda
- Department of Metabolic Medicine, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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24
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Del Roio Liberatore R, Ramos PM, Guerra G, Manna TD, Silva IN, Martinelli CE. Clinical and molecular data from 61 Brazilian cases of Congenital Hyperinsulinemic Hypoglycemia. Diabetol Metab Syndr 2015; 7:5. [PMID: 25972930 PMCID: PMC4429972 DOI: 10.1186/1758-5996-7-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 01/14/2015] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To study the clinical and molecular characteristics of a sample of Brazilian patients with Congenital Hyperinsulinemic Hypoglycemia (CHH). METHODS Electronic message was sent to members from Endocrinology Department- Brazilian Society of Pediatrics requesting clinical data for all cases of CHH. A whole blood sample from living patients was requested for DNA extraction followed by a search for mutations of the genes ABCC8, KCNJ11, GCK, GLUD1, HADH, SLC16A1 and HNF4A. RESULTS Of the 61 patients evaluated, 36 (59%) were boys, and only 16 (26%) were born by normal delivery. Gestational age ranged from 32 to 41 weeks (mean = 37 weeks and 6 days). Birth weight ranged from 1590 to 5250 g (mean = 3430 g). Macrossomia occurred in 14 cases (28%). Age at diagnosis ranged from 1 to 1080 days (mean = 75 days). DNA for molecular analysis was obtained from 53 of the 61 patients. Molecular changes in the ABCC8 gene were detected in 15 (28%) of these 53 cases, and mutations in the KCNJ11 gene were detected in 6 (11%). Mutations in the GLUD1 gene were detected in 9 cases (17%) of the total series. Mutations of the GCK gene in heterozygosis were detected in 3 cases. No mutations were detected in the sequencing of genes HADH, SLC16A1 and HNF4A. CONCLUSION The present study conducted in Brazil permitted the collaborative compilation of an important number of CHH cases and showed that the present clinical and molecular data are similar to those of published global series.
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Affiliation(s)
- Raphael Del Roio Liberatore
- />Ribeirão Preto Medical School, University of São Paulo, Rua Elzira Sammarco Palma, 400/43, Ribeirão Preto, SP Brazil
| | - Priscila Manzini Ramos
- />Ribeirão Preto Medical School, University of São Paulo, Rua Elzira Sammarco Palma, 400/43, Ribeirão Preto, SP Brazil
| | - Gil Guerra
- />Department of Pediatrics, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP Brazil
| | - Thais Della Manna
- />Pediatric Endocrine Unit, Instituto da Criança-Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo, SP Brazil
| | - Ivani Novato Silva
- />Pediatrics Department, Medical School/ Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Carlos Eduardo Martinelli
- />Ribeirão Preto Medical School, University of São Paulo, Rua Elzira Sammarco Palma, 400/43, Ribeirão Preto, SP Brazil
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25
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Su C, Gong C, Sanger P, Li W, Wu D, Gu Y, Cao B. Long-term follow-up and mutation analysis of 27 chinese cases of congenital hyperinsulinism. Horm Res Paediatr 2014; 81:169-76. [PMID: 24434300 DOI: 10.1159/000356911] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 09/24/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Long-term clinical follow-up and mutation analysis were performed in 27 Chinese congenital hyperinsulinism patients. METHOD 27 hypoglycemia patients were diagnosed with CHI within 2 years of age. The long-term clinical outcome was analyzed and mutation analysis of 5 hyperinsulinism candidate genes was performed. RESULTS The median onset age of hypoglycemia in the patients was 60 days; 11 patients showed hypoglycemic symptoms in the neonatal stage, and hypoglycemia in most of the patients was first expressed as a seizure. Blood was collected during the hypoglycemic episode and insulin levels were significantly elevated. ABCC8, KCNJ11, GCK, HNF4a and GLUD1 genes were screened for mutation analysis. 14 mutations in ABCC8 or KCNJ11 genes in 12 cases were identified (44%). 57% (8/14) of the mutations have not been reported before. 83% (10/12) of the patients have a monoallelic mutation. 58% of these 12 patients were predicted to be focal. 73% of the patients without KATP channel mutations were sensitive to diazoxide. 26 patients were followed over a period of 1-13 years. 50% of all 27 patients showed brain impairment. CONCLUSIONS Chinese CHI patients are similar to other ethnic groups in terms of prevalence of KATP-HI, onset age, severity of hypoglycemia and treatment. Mutations in ABCC8 and KCNJ11 are common causes of CHI in Chinese patients. Mutation analysis showed more novel and monoallele mutations in KATP genes.
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Affiliation(s)
- Chang Su
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, Beijing, China
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26
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Maiorana A, Barbetti F, Boiani A, Rufini V, Pizzoferro M, Francalanci P, Faletra F, Nichols CG, Grimaldi C, de Ville de Goyet J, Rahier J, Henquin JC, Dionisi-Vici C. Focal congenital hyperinsulinism managed by medical treatment: a diagnostic algorithm based on molecular genetic screening. Clin Endocrinol (Oxf) 2014; 81:679-88. [PMID: 24383515 DOI: 10.1111/cen.12400] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/24/2013] [Accepted: 12/31/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Congenital hyperinsulinism (CHI) requires rapid diagnosis and treatment to avoid irreversible neurological sequelae due to hypoglycaemia. Aetiological diagnosis is instrumental in directing the appropriate therapy. Current diagnostic algorithms provide a complete set of diagnostic tools including (i) biochemical assays, (ii) genetic facility and (iii) state-of-the-art imaging. They consider the response to a therapeutic diazoxide trial an early, crucial step before proceeding (or not) to specific genetic testing and eventually imaging, aimed at distinguishing diffuse vs focal CHI. However, interpretation of the diazoxide test is not trivial and can vary between research groups, which may lead to inappropriate decisions. Objective of this report is proposing a new algorithm in which early genetic screening, rather than diazoxide trial, dictates subsequent clinical decisions. PATIENTS, METHODS AND RESULTS Two CHI patients weaned from parenteral glucose infusion and glucagon after starting diazoxide. No hypoglycaemia was registered during a 72-h continuous glucose monitoring (CGMS), or hypoglycaemic episodes were present for no longer than 3% of 72-h. Normoglycaemia was obtained by low-medium dose diazoxide combined with frequent carbohydrate feeds for several years. We identified monoallelic, paternally inherited mutations in KATP channel genes, and (18) F-DOPA PET-CT revealed a focal lesion that was surgically resected, resulting in complete remission of hypoglycaemia. CONCLUSIONS Although rare, some patients with focal lesions may be responsive to diazoxide. As a consequence, we propose an algorithm that is not based on a 'formal' diazoxide response but on genetic testing, in which patients carrying paternally inherited ABCC8 or KCNJ11 mutations should always be subjected to (18) F-DOPA PET-CT.
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Affiliation(s)
- Arianna Maiorana
- Department of Pediatrics, Metabolic Unit, IRCCS Bambino Gesù Children's Hospital, Rome, Italy
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27
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Chandran S, Yap F, Hussain K. Molecular mechanisms of protein induced hyperinsulinaemic hypoglycaemia. World J Diabetes 2014; 5:666-677. [PMID: 25317244 PMCID: PMC4138590 DOI: 10.4239/wjd.v5.i5.666] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 04/23/2014] [Accepted: 05/29/2014] [Indexed: 02/05/2023] Open
Abstract
The interplay between glucose metabolism and that of the two other primary nutrient classes, amino acids and fatty acids is critical for regulated insulin secretion. Mitochondrial metabolism of glucose, amino acid and fatty acids generates metabolic coupling factors (such as ATP, NADPH, glutamate, long chain acyl-CoA and diacylglycerol) which trigger insulin secretion. The observation of protein induced hypoglycaemia in patients with mutations in GLUD1 gene, encoding the enzyme glutamate dehydrogenase (GDH) and HADH gene, encoding for the enzyme short-chain 3-hydroxyacyl-CoA dehydrogenase has provided new mechanistic insights into the regulation of insulin secretion by amino acid and fatty acid metabolism. Metabolic signals arising from amino acid and fatty acid metabolism converge on the enzyme GDH which integrates both signals from both pathways and controls insulin secretion. Hence GDH seems to play a pivotal role in regulating both amino acid and fatty acid metabolism.
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28
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Martens P, Tits J. Approach to the patient with spontaneous hypoglycemia. Eur J Intern Med 2014; 25:415-21. [PMID: 24641805 DOI: 10.1016/j.ejim.2014.02.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 02/27/2014] [Accepted: 02/28/2014] [Indexed: 12/18/2022]
Abstract
UNLABELLED Hypoglycemia is common in daily clinical practice and often occurs during the treatment of diabetes mellitus. However, a small minority of hypoglycemia encountered in clinical practice is spontaneous and thus not induced by glycemic lowering agents. These spontaneous hypoglycemic events confront the clinician with a diagnostic enigma. Although the trained clinician can recognize the autonomic and neuroglycopenic symptoms of hypoglycemia even in a patient not on insulin, it remains challenging to decipher the etiology of a spontaneous hypoglycemic event. A logical and stepwise approach to the spontaneous hypoglycemic event allows for a conclusive diagnosis. This diagnostic process consists of adequately diagnosing hypoglycemia by fulfilling Whipple's triad, stratifying patients according to their clinical status and analyzing a full hypoglycemic blood panel. A complete hypoglycemic blood panel should include the analysis of glucose, insulin, C-peptide, pro-insulin, insulin antibodies and the presence of oral hypoglycemic agents. For patients with episodes of hypoglycemia induced by excessive endogenous insulin, additional imaging is often required to detect the presence of an underlying insulinoma. By diagnosing the underlying cause of the spontaneous hypoglycemia, the physician also diagnosis the mechanism by which the hypoglycemic event occurs. Allowing for a problem orientated therapeutic approach. METHODOLOGY The present review is based upon a comprehensive PubMed search between 1985 and 2013. This uses search terms of spontaneous hypoglycemia, insulinoma, nesidioblastosis, insulin auto-immunity, noninsulinoma pancreatogenous hypoglycemia syndrome, hormone deficiency, pro-IGF II, and pro-insulin growth factor II, and cross reference searching of pivotal articles in the subject.
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Affiliation(s)
- Pieter Martens
- Department of Internal Medicine, University Hospital Gasthuisberg Leuven, KU Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Jos Tits
- Department of Endocrinology, Hospital Ziekenhuis Oost-Limburg ZOL, Genk, Belgium
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Abstract
Persistent hyperinsulinaemic hypoglycaemia in infancy (PHHI) is a heterogeneous condition characterised by unregulated insulin secretion in response to a low blood glucose level. It is the most common cause of severe and persistent hypoglycaemia in neonates. It is extremely important to recognise this condition early and institute appropriate management to prevent significant brain injury leading to complications like epilepsy, cerebral palsy and neurological impairment. Histologically, PHHI is divided mainly into three types-diffuse, focal and atypical disease. Fluorine-18-l-3,4-dihydroxyphenylalanine positron emission tomography (18F-DOPA-PET/CT) scan allows differentiation between diffuse and focal diseases. 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 molecular basis of PHHI involves defects in key genes (ABCC8, KCNJ11, GCK, SLC16A1, HADH, UCP2, HNF4A and GLUD1) that regulate insulin secretion. Focal lesions are cured by lesionectomy whereas diffuse disease (unresponsive to medical therapy) will require a near-total pancreatectomy with a risk of developing diabetes mellitus and pancreatic exocrine insufficiency. Open surgery is the traditional approach to pancreatic resection. However, recent advances in laparoscopic surgery have led to laparoscopic near-total pancreatectomy for diffuse lesions and laparoscopic distal pancreatectomy for focal lesions distal to the head of the pancreas.
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Affiliation(s)
- Pratik Shah
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London
| | - Huseyin Demirbilek
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London
| | - Khalid Hussain
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London.
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30
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Mathur S, Boparai J, Mediwala SN, Garcia JM, Cunningham GR, Marcelli M, Vasudevan MM. Reversible Adrenal Insufficiency in Three Patients With Post-Roux-en-Y Gastric Bypass Noninsulinoma Pancreatogenous Hypoglycemia Syndrome. J Investig Med High Impact Case Rep 2014; 2:2324709614526992. [PMID: 26425596 PMCID: PMC4528859 DOI: 10.1177/2324709614526992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Objective. Noninsulinoma pancreatogenous hypoglycemia syndrome (NIPHS) is a disorder of endogenous hyperinsulinemia that is clinically distinguishable from insulinoma, with a greater preponderance after Roux-en-Y gastric bypass (RYBG). Hyperinsulinemic hypoglycemia can predispose to attenuation of counterregulatory hormone responses to hypoglycemia, and consequent suppression of the hypothalamic-pituitary-adrenal (HPA) axis. This case series describes 3 individuals who were diagnosed with adrenal insufficiency (AI) after undergoing RYGB, complicated by NIPHS. Methods. A retrospective chart review was performed for each individual. Chart review applied particular attention to the onset of hyperinsulinemic hypoglycemia following bariatric surgery and the dynamic testing leading to the diagnoses of NIPHS and AI. Results. In each case, reactive hypoglycemia ensued within months to years after RYGB. Cosyntropin stimulation testing confirmed the diagnosis of AI. Hydrocortisone therapy reduced the frequency and severity of hypoglycemia and was continued until successful medical and/or surgical management of hyperinsulinism occurred. Follow-up testing of the HPA axis demonstrated resolution of AI. In all cases, hydrocortisone therapy was finally discontinued without incident. Conclusion. We speculate that transient AI is a potential complication in patients who experience recurrent hyperinsulinemic hypoglycemia after RYGB. The putative mechanism for this observation may be attenuation of the HPA axis after prolonged exposure to severe, recurrent hypoglycemia. We conclude that biochemical screening for AI should be considered in individuals who develop post-RYGB hyperinsulinemic hypoglycemia. If AI is diagnosed, supportive treatment should be maintained until hyperinsulinemic hypoglycemia has been managed effectively.
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Affiliation(s)
- Shelly Mathur
- Baylor College of Medicine, Houston, TX, USA ; Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | | | - Sanjay N Mediwala
- Baylor College of Medicine, Houston, TX, USA ; Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Jose M Garcia
- Baylor College of Medicine, Houston, TX, USA ; Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | | | - Marco Marcelli
- Baylor College of Medicine, Houston, TX, USA ; Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Madhuri M Vasudevan
- Baylor College of Medicine, Houston, TX, USA ; Michael E. DeBakey VA Medical Center, Houston, TX, USA
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Jindal R, Ahmad A, Siddiqui MA, Kochar IS, Wangnoo SK. Novel mutation c.597_598dup in exon 5 of ABCC8 gene causing congenital hyperinsulinism. Diabetes Metab Syndr 2014; 8:45-47. [PMID: 24661758 DOI: 10.1016/j.dsx.2013.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Congenital hyperinsulinism (CHI), a clinically and genetically heterogeneous disease, characterized by the unregulated secretion of insulin from pancreatic β-cells, is the most common cause of persistent hypoglycemia in infancy. Early diagnosis and maintenance of normoglycaemia are essential to prevent adverse neurodevelopmental outcomes. The most common and severe forms of CHI are caused by inactivating mutations in ABCC8 and KCNJ11 genes, encoding the two subunits of the pancreatic β-cell ATP sensitive potassium channel (KATP). We report a case of neonatal CHI due to a novel homozygous recessive mutation in the ABCC8 gene.
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Affiliation(s)
- Radhika Jindal
- Department of Endocrinology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India.
| | - Ayesha Ahmad
- Department of Pediatrics, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
| | - Mohammad Asim Siddiqui
- Department of Endocrinology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
| | - Inderpal Singh Kochar
- Department of Pediatrics, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
| | - Subhash Kumar Wangnoo
- Department of Endocrinology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, India
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18F-DOPA PET and enhanced CT imaging for congenital hyperinsulinism: initial UK experience from a technologist's perspective. Nucl Med Commun 2013; 34:601-8. [PMID: 23571817 DOI: 10.1097/mnm.0b013e32836069d0] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycaemia in infants and children. Histologically, there are two subgroups, diffuse and focal. The aim of this study was to evaluate the accuracy of (18)F-fluoro-L-dihydroxyphenylalanine ((18)F-DOPA) PET/computed tomography (CT) and contrast-enhanced CT in distinguishing between focal and diffuse lesions in infants with CHI who are unresponsive to medical therapy. In addition, this paper describes the detailed protocol used for imaging and analysis of (18)F-DOPA PET/CT images in our clinical practice. MATERIALS AND METHODS Twenty-two (18)F-DOPA PET/CT and contrast-enhanced CT imaging studies were carried out on 18 consecutive patients (nine boys and nine girls) with CHI (median age, 2 years and 1 month; range, 1-84 months) who had positive dominant ABCC8 mutation genetic results or negative ABCC8/t results but did not respond to first-line medical therapy with high-dose diazoxide. (18)F-DOPA was produced by the cyclotron unit of Woolfson Molecular Imaging Centre, Manchester, and transported to our centre in central London after synthesis and implementation of quality control measures. (18)F-DOPA was administered intravenously at a dose of 4 MBq/kg, and iodine contrast medium was injected intravenously at a dose of 1.5 ml/kg. Single bed position PET/CT images of the pancreas were acquired under light sedation with oral chloral hydrate. Four PET dynamic data acquisition scans were taken 20, 40, 50 and 60 min after injection for a duration of 10 min each. The results were assessed by visual interpretation and quantitative measurements of standardized uptake values (SUVs) in the head, body, and tail of the pancreas. RESULTS Of the 18 patients, 13 showed diffuse and five showed focal (18)F-DOPA PET pancreatic uptake. Three regions of interest were drawn over the head, body and tail of the pancreas to calculate the SUV(max). Using the formula - highest SUV(max)/next highest SUV(max) - a ratio was calculated. Five patients had an accumulation of F-DOPA in the pancreas and an SUV ratio greater than 1.5, indicating focal disease with an SUV(max) more than 50% higher than that of the unaffected areas of the pancreas. The remaining 13 patients had diffuse accumulation of (18)F-DOPA in the pancreas (SUV ratio<1.3). Using this ratio, a focal lesion can be distinguished from diffuse uptake and normal pancreatic uptake. The sizes of these regions of interest varied according to the age of the child. All patients diagnosed with focal lesions underwent surgery and were cured eventually. Lesions were accurately localized by PET/CT and confirmed by histological results after surgery. Three of these patients had to undergo second (18)F-DOPA scans and second surgeries after unsuccessful excision during their first surgery. Three patients with diffuse disease underwent a partial pancreatectomy, and histological results confirmed diffuse disease. One patient was cured and two remain on high-dose diazoxide therapy because of persistent hypoglycaemia. CONCLUSION (18)F-DOPA PET/CT offers excellent differentiation of focal from diffuse CHI, and the contrast-enhanced CT technique permits precise preoperative localization of the lesion and anatomical landmarks.
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Campos GM, Ziemelis M, Paparodis R, Ahmed M, Davis DB. Laparoscopic reversal of Roux-en-Y gastric bypass: technique and utility for treatment of endocrine complications. Surg Obes Relat Dis 2013; 10:36-43. [PMID: 24120983 DOI: 10.1016/j.soard.2013.05.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 04/24/2013] [Accepted: 05/25/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND The anatomic and physiologic changes with Roux-en-Y gastric bypass (RYGB) may lead to uncommon but occasionally difficult to treat complications such as hyperinsulinemic hypoglycemia with neuroglycopenia and recalcitrant hypocalcemia associated to hypoparathyroidism. Medical management of these complications is challenging. Laparoscopic reversal of RYGB anatomy with restoration of pyloric function and duodenal continuity is a potential treatment. The objective of this study was to present the indications, surgical technique, and clinical outcomes of laparoscopic reversal of RYGB. METHODS Prospective study of consecutive patients offered laparoscopic reversal of RYGB. RESULTS Five patients with remote laparoscopic RYGB underwent laparoscopic reversal of RYGB to normal anatomy (n = 2) or modified sleeve gastrectomy (n = 3). Indications were medically refractory hyperinsulinemic hypoglycemia with neuroglycopenia (n = 3), recalcitrant hypocalcemia with hypoparathyroidism (n = 1), and both conditions simultaneously (n = 1). Before reversal, all patients had a gastrostomy tube placed in the excluded stomach to document improvement of symptoms. Laparoscopic reversal was accomplished successfully in all patients. Three postoperative complications occurred: bleeding that required transfusion, gallstone pancreatitis, and a superficial trocar site infection. Average length of stay was 3 days. At a mean follow-up of 12 months (range 3 to 22), no additional episodes of neuroglycopenia occurred, average number of hypoglycemic episodes per week decreased from 18.5 ± 12.4 to 1.5 ± 1.9 (P = .05), and hypocalcemia became responsive to oral replacement therapy in both patients. CONCLUSIONS Laparoscopic reversal of RYGB to normal anatomy or modified sleeve gastrectomy is feasible and may be a therapeutic option for selected patients with medically refractory hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated with hypoparathyroidism.
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Affiliation(s)
- Guilherme M Campos
- Department of Surgery, Division of General Surgery, Section of Foregut and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin.
| | - Martynas Ziemelis
- Department of Surgery, Division of General Surgery, Section of Foregut and Bariatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Rodis Paparodis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Muhammed Ahmed
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Dawn Belt Davis
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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34
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Faletra F, Athanasakis E, Morgan A, Biarnés X, Fornasier F, Parini R, Furlan F, Boiani A, Maiorana A, Dionisi-Vici C, Giordano L, Burlina A, Ventura A, Gasparini P. Congenital hyperinsulinism: clinical and molecular analysis of a large Italian cohort. Gene 2013; 521:160-5. [PMID: 23506826 DOI: 10.1016/j.gene.2013.03.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 03/07/2013] [Indexed: 11/15/2022]
Abstract
Congenital hyperinsulinism (CHI) is a genetic disorder characterized by profound hypoglycemia related to an inappropriate insulin secretion. It is a heterogeneous disease classified into two major subgroups: "channelopathies" due to defects in ATP-sensitive potassium channel, encoded by ABCC8 and KCNJ11 genes, and "metabolopathies" caused by mutation of several genes (GLUD1, GCK, HADH, SLC16A1, HNF4A and HNF1A) and involved in different metabolic pathways. To elucidate the genetic etiology of CHI in the Italian population, we conducted an extensive sequencing analysis of the CHI-related genes in a large cohort of 36 patients: Twenty-nine suffering from classic hyperinsulinism (HI) and seven from hyperinsulinism-hyperammonemia (HI/HA). Seventeen mutations have been found in fifteen HI patients and five mutations in five HI/HA patients. Our data confirm the major role of ATP-sensitive potassium channel in the pathogenesis of Italian cases (~70%) while the remaining percentage should be attributed to other. A better knowledge of molecular basis of CHI would lead to improve strategies for genetic screening and prenatal diagnosis. Moreover, genetic analysis might also help to distinguish the two histopathological forms of CHI, which would lead to a clear improvement in the treatment and in genetic counseling.
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Affiliation(s)
- Flavio Faletra
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy.
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Liberatore Junior RDR, Negri AA, Martinelli Junior CE, Kochi C, Silva IN, Collett-Solberg PF. [Hyperinsulinemic hypoglycemia of the infancy: analysis of clinical data from a Brazilian sample]. ACTA ACUST UNITED AC 2013; 56:666-71. [PMID: 23329191 DOI: 10.1590/s0004-27302012000900011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 10/16/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To review the presentation of hyperinsulinemic hypoglycemia of the infancy (HHI), its treatment and histology in Brazilian pediatric endocrinology sections. MATERIALS AND METHOD The protocol analyzed data of birth, laboratory results, treatment, surgery, and pancreas histology. RESULTS Twenty-five cases of HHI from six centers were analyzed: 15 male, 3/25 born by vaginal delivery. The average age at diagnosis was 10.3 days. Glucose and insulin levels in the critical sample showed an average of 24.7 mg/dL and 26.3 UI/dL. Intravenous infusion of the glucose was greater than 10 mg/kg/min in all cases (M:19,1). Diazoxide was used in 15/25 of the cases, octreotide in 10, glucocorticoid in 8, growth hormone in 3, nifedipine in 2 and glucagon in 1. Ten of the cases underwent pancreatectomy and histology results showed the diffuse form of disease. CONCLUSION This is the first critic review of a Brazilian sample with congenital HHI.
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Banerjee I, Avatapalle B, Petkar A, Skae M, Padidela R, Ehtisham S, Patel L, Rigby L, Flanagan S, Ellard S, Jones C, Ciotti G, Malaiya N, Clayton PE. The association of cardiac ventricular hypertrophy with congenital hyperinsulinism. Eur J Endocrinol 2012; 167:619-24. [PMID: 22894813 DOI: 10.1530/eje-12-0632] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Ventricular hypertrophy (VH) has been observed in children with congenital hyperinsulinism (CHI), a condition of hypoglycaemia characterised by dysregulated insulin secretion, but the prevalence is not known. PATIENTS AND METHODS Cardiac assessment was performed in children (n=49) with CHI at diagnosis and follow-up. Two dimensional and Doppler echocardiography studies were used to assess cardiac structures, while M-mode study was used to measure left ventricular (LV) dimensions, subsequently converted to Z scores. Where possible, LV hypertrophy was confirmed by LV mass index (g/m(2.7)) >95th centile. RESULTS Cardiac structural lesions were found in 14 (28%) children. At initial echocardiography, VH was present in 31 (65%) children with median (range) LV posterior wall dimension in diastole Z scores of +1.6 (-2.4 to +5.8) and interventricular septal wall dimension in end diastole Z scores of +1.9 (-1.7 to +17.2). At follow-up echocardiography, performed after an interval of 178 (45-390) days, VH persisted in 16 (33%) children. In regression analysis, the presence of VH (odds ratio (95% confidence intervals) 1.1 (1.0-1.2), P=0.04) at initial echocardiography was correlated with maximum glucose requirement at diagnosis, indicating that severity of CHI at presentation may play a role in the pathogenesis of VH. CONCLUSIONS A significant proportion of children with CHI have cardiac structural lesions. A majority also have VH, which may be associated with the severity of CHI at diagnosis. VH may persist in some children, which requires careful long-term cardiac review.
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Affiliation(s)
- Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, UK.
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Neonatal hepatoblastoma in a newborn with severe phenotype of Beckwith-Wiedemann syndrome. Eur J Pediatr 2011; 170:1407-11. [PMID: 21448630 DOI: 10.1007/s00431-011-1455-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 03/14/2011] [Indexed: 10/18/2022]
Abstract
Beckwith-Wiedemann syndrome is an overgrowth disorder characterized by neonatal macrosomia, abdominal wall defects, macroglossia, renal anomalies, organomegaly, hypoglycemia, and cancer predisposition. Hepatoblastoma is the second most frequent tumor and periodic serum alpha-fetoprotein (αFP) dosage is the cornerstone of the tumor surveillance for its early detection. In this report, we describe the outstanding case of a Beckwith-Wiedemann syndrome (BWS) newborn with severe phenotype and paternal chromosome 11 uniparental disomy (UPD11) associated with a high tumor risk. Based on the clinical picture and previous reports, a close monitoring of αFP was commenced. The marker was normal immediately after birth, but rapidly raised in 20 days, leading to the diagnosis of an extremely aggressive hepatoblastoma. The latter was successfully treated with pre-surgical reductive chemotherapy, gross total mass resection, and subsequent chemotherapy. Based on this observation, the tumor surveillance routinely suggested every 3 months should be more intense and with closer time intervals in newborns with severe BWS phenotype. We suggest monitoring neonatal αFP every 20 days in such cases.
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Kapoor RR, Flanagan SE, James CT, McKiernan J, Thomas AM, Harmer SC, Shield JP, Tinker A, Ellard S, Hussain K. Hyperinsulinaemic hypoglycaemia and diabetes mellitus due to dominant ABCC8/KCNJ11 mutations. Diabetologia 2011; 54:2575-83. [PMID: 21674179 PMCID: PMC3168751 DOI: 10.1007/s00125-011-2207-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 05/06/2011] [Indexed: 11/30/2022]
Abstract
AIMS/HYPOTHESIS Dominantly acting loss-of-function mutations in the ABCC8/KCNJ11 genes can cause mild medically responsive hyperinsulinaemic hypoglycaemia (HH). As controversy exists over whether these mutations predispose to diabetes in adulthood we investigated the prevalence of diabetes in families with dominantly inherited ATP-sensitive potassium (K(ATP)) channel mutations causing HH in the proband. METHODS We studied the phenotype of 30 mutation carriers (14 children and 16 adults) from nine families with dominant ABCC8/KCNJ11 mutations. Functional consequences of six novel missense mutations were examined by reconstituting the K(ATP) channel in human embryonic kidney 293 (HEK293) cells and evaluating the effect of drugs and metabolic poisoning on the channels using the (86)Rb flux assay. RESULTS The mutant channels all showed a lack of (86)Rb efflux on exposure to the channel agonist diazoxide or metabolic inhibition. In the families, dominant ABCC8/KCNJ11 mutations were associated with increased birthweight (median + 1.56 SD score [SDS]). Fourteen children had HH and five adults were reported with HH or hypoglycaemic episodes (63%). Progression from hypoglycaemia to diabetes mellitus occurred in two individuals. Eight adults had a history of gestational diabetes in multiple pregnancies or were diabetic (diagnosed at a median age of 31 years). Within these families, none of the 19 adults who were not carriers of the ABCC8/KCNJ11 mutation was known to be diabetic. CONCLUSIONS/INTERPRETATION The phenotype associated with dominant ABCC8/KCNJ11 mutations ranges from asymptomatic macrosomia to persistent HH in childhood. In adults, it may also be an important cause of dominantly inherited early-onset diabetes mellitus.
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Affiliation(s)
- R. R. Kapoor
- Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH UK
| | - S. E. Flanagan
- Institute of Biomedical and Clinical Science, Peninsula Medical School, University of Exeter, Exeter, UK
| | - C. T. James
- Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH UK
| | | | - A. M. Thomas
- BHF Laboratories, Department of Medicine, University College London, London, UK
| | - S. C. Harmer
- BHF Laboratories, Department of Medicine, University College London, London, UK
| | - J. P. Shield
- Bristol Royal Hospital for Children, Bristol, UK
| | - A. Tinker
- BHF Laboratories, Department of Medicine, University College London, London, UK
| | - S. Ellard
- Institute of Biomedical and Clinical Science, Peninsula Medical School, University of Exeter, Exeter, UK
| | - K. Hussain
- Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, 30 Guilford Street, London, WC1N 1EH UK
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Masue M, Nishibori H, Fukuyama S, Yoshizawa A, Okamoto S, Doi R, Uemoto S, Tokumi T, Kasai T, Yorifuji T. Diagnostic accuracy of [¹⁸F]-fluoro-L-dihydroxyphenylalanine positron emission tomography scan for persistent congenital hyperinsulinism in Japan. Clin Endocrinol (Oxf) 2011; 75:342-6. [PMID: 21521340 DOI: 10.1111/j.1365-2265.2011.04072.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE We aimed to elucidate the accuracy and limitations of [(18)F]-fluoro-L-dihydroxyphenylalanine ([(18) F]DOPA) positron emission tomography (PET) for Japanese patients with congenital hyperinsulinism. Although [(18)F]DOPA PET is reported to be useful for precisely localizing the focal form of congenital hyperinsulinism, previous reports are mostly from European and North American centres. PATIENTS Seventeen Japanese infants with congenital hyperinsulinism. MEASUREMENTS [(18)F]DOPA PET studies were carried out, and the results were assessed by simple inspection or by a quantitative measurement termed the 'Pancreas Percentage', which expresses the uptake of the head, body or tail of the pancreas as a percentage of the total maximum standardized uptake value of the whole pancreas. The results were compared with those of other studies, including genetic analysis and histology. RESULTS By simple inspection, when a single focal uptake was obtained, the localization and histology were correct in all cases that underwent pancreatectomy. However, the overall results were consistent with the molecular diagnosis and histology in only 7/17 and 6/12 patients, respectively. The inaccuracy of PET studies by inspection was because of elevated background uptake that mimicked a diffuse or multifocal appearance. The accuracy improved substantially using the Pancreas Percentage; it was consistent with the molecular diagnosis and histology in 10/17 and 9/12 patients, respectively. CONCLUSIONS In contrast to the results of previous reports, [(18)F]DOPA PET appears to be less efficient for diagnosing Japanese patients with congenital hyperinsulinism. However, the diagnostic accuracy is substantially improved when this technique is combined with the Pancreas Percentage.
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Affiliation(s)
- Michiya Masue
- Department of Pediatrics, Kizawa Memorial Hospital, Chubu Medical Center for Prolonged Traumatic Brain Dysfunction, Gifu, Japan.
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Banerjee I, Skae M, Flanagan SE, Rigby L, Patel L, Didi M, Blair J, Ehtisham S, Ellard S, Cosgrove KE, Dunne MJ, Clayton PE. The contribution of rapid KATP channel gene mutation analysis to the clinical management of children with congenital hyperinsulinism. Eur J Endocrinol 2011; 164:733-40. [PMID: 21378087 DOI: 10.1530/eje-10-1136] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In children with congenital hyperinsulinism (CHI), K(ATP) channel genes (ABCC8 and KCNJ11) can be screened rapidly for potential pathogenic mutations. We aimed to assess the contribution of rapid genetic testing to the clinical management of CHI. DESIGN Follow-up observational study at two CHI referral hospitals. METHODS Clinical outcomes such as subtotal pancreatectomy, (18)F-Dopa positron emission tomography-computed tomography (PET-CT) scanning, stability on medical treatment and remission were assessed in a cohort of 101 children with CHI. RESULTS In total, 32 (32%) children had pathogenic mutations in K(ATP) channel genes (27 in ABCC8 and five in KCNJ11), of which 11 (34%) were novel. In those negative at initial screening, other mutations (GLUD1, GCK, and HNF4A) were identified in three children. Those with homozygous/compound heterozygous ABCC8/KCNJ11 mutations were more likely to require a subtotal pancreatectomy CHI (7/10, 70%). Those with paternal heterozygous mutations were investigated with (18)F-Dopa PET-CT scanning and 7/13 (54%) had a focal lesionectomy, whereas four (31%) required subtotal pancreatectomy for diffuse CHI. Those with maternal heterozygous mutations were most likely to achieve remission (5/5, 100%). In 66 with no identified mutation, 43 (65%) achieved remission, 22 (33%) were stable on medical treatment and only one child required a subtotal pancreatectomy. CONCLUSIONS Rapid genetic analysis is important in the management pathway of CHI; it provides aetiological confirmation of the diagnosis, indicates the likely need for a subtotal pancreatectomy and identifies those who require (18)F-Dopa PET-CT scanning. In the absence of a mutation, reassurance of a favourable outcome can be given early in the course of CHI.
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Affiliation(s)
- I Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester M13 9WL, UK.
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Ashrafian H, Athanasiou T, Li JV, Bueter M, Ahmed K, Nagpal K, Holmes E, Darzi A, Bloom SR. Diabetes resolution and hyperinsulinaemia after metabolic Roux-en-Y gastric bypass. Obes Rev 2011; 12:e257-72. [PMID: 20880129 DOI: 10.1111/j.1467-789x.2010.00802.x] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The global prevalence of type 2 diabetes mellitus and impaired glucose metabolism continues to rise in conjunction with the pandemic of obesity. The metabolic Roux-en-Y gastric bypass operation offers the successful resolution of diabetes in addition to sustained weight loss and excellent long-term outcomes in morbidly obese individuals. The procedure consists of the physiological BRAVE effects: (i) Bile flow alteration; (ii) Reduction of gastric size; (iii) Anatomical gut rearrangement and altered flow of nutrients; (iv) Vagal manipulation and (v) Enteric gut hormone modulation. This operation provides anti-diabetic effects through decreasing insulin resistance and increasing the efficiency of insulin secretion. These metabolic outcomes are achieved through weight-independent and weight-dependent mechanisms. These include the foregut, midgut and hindgut mechanisms, decreased inflammation, fat, adipokine and bile metabolism, metabolic modulation, shifts in gut microbial composition and intestinal gluconeogenesis. In a small minority of patients, gastric bypass results in hyperinsulinaemic hypoglycaemia that may lead to nesidioblastosis (pancreatic beta-cell hypertrophy with islet hyperplasia). Elucidating the precise metabolic mechanisms of diabetes resolution and hyperinsulinaemia after surgery can lead to improved operations and disease-specific procedures including 'diabetes surgery'. It can also improve our understanding of diabetes pathogenesis that may provide novel strategies for the management of metabolic syndrome and impaired glucose metabolism.
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Affiliation(s)
- H Ashrafian
- The Department of Surgery and Cancer, Imperial College London, London, UK.
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Liberatore Junior RDR, Martinelli Junior CE. [Hypoglycemia hypersinsulinemic of infancy]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2011; 55:177-83. [PMID: 21655865 DOI: 10.1590/s0004-27302011000300001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2001] [Accepted: 04/18/2011] [Indexed: 11/21/2022]
Abstract
The hypoglycemia hyperinsulinemic of the infancy (HHI) is an emergency in the neonatal period. After a short period of fast the avid brain runs out of its main energy substrate. The authors overhaul the diagnosis of HH, not only in the neonatal period, but also in the late infant and in the adolescence. The aspects of the molecular alterations found in these cases, as well like the description of the main mutations are also approached.
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Affiliation(s)
- Raphael Del Roio Liberatore Junior
- Serviço de Endocrinologia Pediátrica, Departamento de Pediatria e Cirurgia Pediátrica, Faculdade de Medicina de São José do Rio Preto, SP, Brasil.
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Vanderveen KA, Grant CS, Thompson GB, Farley DR, Richards ML, Vella A, Vollrath B, Service FJ. Outcomes and quality of life after partial pancreatectomy for noninsulinoma pancreatogenous hypoglycemia from diffuse islet cell disease. Surgery 2011; 148:1237-45; discussion 1245-6. [PMID: 21134557 DOI: 10.1016/j.surg.2010.09.027] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Accepted: 09/16/2010] [Indexed: 01/11/2023]
Abstract
BACKGROUND Noninsulinoma pancreatogenous hypoglycemia (NIPH) is a rare cause of hypoglycemia, especially affecting postbariatric surgery patients, related to excessive insulin secretion. Partial pancreatectomy controls hypoglycemia in the early postoperative period; however, multiple patients have experienced symptomatic relapse. The study goal was to assess frequency and severity of recurrent symptoms in operated patients. METHODS All patients who underwent pancreatic resection for NIPH at Mayo Clinic from January 1996 through December 2008 were reviewed for demographics, preoperative testing, operative and postoperative details. Data from patient records, mail survey, European Quality of Life Survey (EQ-5D), and Fear of Hypoglycemia Scale (FOHS) were used to assess outcome. RESULTS Seventy-five patients underwent pancreatic resection for NIPH (5 dead, 1 incarcerated). 48 patients (70%) completed the survey; mean follow-up, 53 months. Median time to recurrent symptoms was 16 months in 41 patients (87%). Despite symptom recurrence, 36 patients (75%) reported overall improvement in symptoms and quality of life (QOL); median EQ-5D health scores increased from 40 to 75 out of 100 (P < .001). Moreover, they reported marked reduction in psychologic stress and hypoglycemic symptoms with greater than 50% decrease in FOHS overall, worry, and behavioral median scores (P < .001). Overall, half of the patients were classified as highly/moderately surgically successful, whereas the other half was minimally successful or surgical failures. CONCLUSION Although nearly 90% of NIPH patients reported recurrent symptoms suggestive of hypoglycemia, a majority reported improvements in QOL and marked reduction in other symptoms after pancreatic resection. Nevertheless, 25% of patients experienced no benefit from partial pancreatectomy.
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Gisslen T, Nathan B, Thompson T, Rao R. Hyperinsulinism associated with gestational exposure to bupropion in a newborn infant. J Pediatr Endocrinol Metab 2011; 24:819-22. [PMID: 22145484 DOI: 10.1515/jpem.2011.317] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This case report describes severe hyperinsulinism in a term newborn infant without typical perinatal risk factors for transient hyperinsulinism. The mother had received bupropion, an antidepressant and aid to smoking cessation, throughout pregnancy. The infant presented with profound hypoglycemia and seizures on the 3rd day of life. Laboratory investigation confirmed hyperinsulinism. Stable euglycemia could be achieved only after starting diazoxide. The infant was weaned from diazoxide by 10 weeks of age without recurrence of hypoglycemia, signifying the transient nature of hyperinsulinism. This is the first reported case of a potential association between maternal bupropion use during pregnancy and neonatal hyperinsulinism, and highlights the importance of close monitoring of similar infants.
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Affiliation(s)
- Tate Gisslen
- Department of Pediatrics, Division of Neonatology, University of Minnesota, Minneapolis 55455, MN, USA
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Padidela R, Kapoor RR, Moyo Y, Gilbert C, Flanagan SE, Ellard S, Hussain K. Focal congenital hyperinsulinism in a patient with septo-optic dysplasia. Nat Rev Endocrinol 2010; 6:646-50. [PMID: 20842182 DOI: 10.1038/nrendo.2010.153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND An infant diagnosed as having hypopituitarism and on adequate hydrocortisone replacement therapy was referred to a tertiary endocrine unit at 5 weeks of age with persistent hypoglycemia that required a high rate of intravenous glucose infusion (up to 18 mg/kg•min⁻¹) to maintain euglycemia. INVESTIGATIONS A controlled hypoglycemia screen was performed to measure levels of plasma glucose, insulin, C-peptide and 3-β-hydroxybutyrate concentrations. The pancreas was analyzed by fluorine-18-L-3,4-dihydroxyphenylalanine ((18)F-DOPA) PET scan. Genetic analyses were performed on the peripheral blood leukocytes, and loss of heterozygosity within the resected focal lesion of the pancreas was investigated by microsatellite analysis. A glucagon stimulation test helped determine pituitary function, and an MRI of the brain and pituitary gland was performed to define the anatomy of the intracranial structures and the pituitary gland. DIAGNOSIS Focal form of congenital hyperinsulinism localized to the head of the pancreas, septo-optic dysplasia and pituitary hormone deficiencies. MANAGEMENT Resection of the focal lesion from the head of the pancreas and hormonal replacement therapy for hypopituitarism.
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Affiliation(s)
- Raja Padidela
- Clinical and Molecular Genetics Unit, UCL Institute of Child Health and Great Ormond Street Hospital for Children, 30 Guilford Street, London WC1N 1EH, UK
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Patti ME, Goldfine AB. Hypoglycaemia following gastric bypass surgery--diabetes remission in the extreme? Diabetologia 2010; 53:2276-9. [PMID: 20730413 DOI: 10.1007/s00125-010-1884-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2010] [Accepted: 07/28/2010] [Indexed: 12/15/2022]
Abstract
Postprandial hypoglycaemia is increasingly recognised as a complication of gastric bypass surgery. While post-bypass hypoglycaemia is often responsive to dietary modification, a subset of individuals develop life-threatening neuroglycopenia, with loss of consciousness, seizures and motor vehicle accidents. Such patients require complex nutritional and medical management strategies to reduce postprandial insulin secretion and stabilise glucose excursions, using medications including acarbose, octreotide and diazoxide, and frequent monitoring of glucose values. In an article in this issue of Diabetologia, nationwide registry data from Sweden were used to assess the frequency of severe hypoglycaemia and potentially related diagnoses (e.g. confusion, syncope, seizures, accidental death) following obesity surgery. Relative risk of hypoglycaemia and related diagnoses were two- to sevenfold higher in the post-gastric bypass population, but absolute risk was small. While these data underscore that hypoglycaemia is an important complication of gastric bypass, many questions regarding frequency, pathogenesis and optimal therapy remain unanswered. Given that hypoglycaemia is usually evaluated in the outpatient setting, more precise assessments of hypoglycaemia frequency will require prospective longitudinal studies in post-bypass cohorts. Until such data are available, practitioners should have a higher awareness of symptoms consistent with neuroglycopenia in patients with a history of bariatric surgery. Understanding the beneficial and challenging metabolic consequences of bariatric surgery is a key imperative for the diabetes community, as such data may yield novel insights into mechanisms by which bariatric surgery can lead to diabetes remission.
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Affiliation(s)
- M E Patti
- Research Division, Joslin Diabetes Center and Harvard Medical School, 1 Joslin Place, Boston, MA 02215, USA.
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Gray SL, Donald C, Jetha A, Covey SD, Kieffer TJ. Hyperinsulinemia precedes insulin resistance in mice lacking pancreatic beta-cell leptin signaling. Endocrinology 2010; 151:4178-86. [PMID: 20631001 DOI: 10.1210/en.2010-0102] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The adipocyte hormone leptin acts centrally and peripherally to regulate body weight and glucose homeostasis. The pancreatic beta-cell has been shown to be a key peripheral target of leptin, with leptin suppressing insulin synthesis and secretion from beta-cells both in vitro and in vivo. Mice with disrupted leptin signaling in beta-cells (lepr(flox/flox) RIPcre tg+ mice) display hyperinsulinemia, insulin resistance, glucose intolerance, obesity, and reduced fasting blood glucose. We hypothesized that hyperinsulinemia precedes the development of insulin resistance and increased adiposity in these mice with a defective adipoinsular axis. To determine the primary defect after impaired beta-cell leptin signaling, we treated lepr(flox/flox) RIPcre tg+ mice with the insulin sensitizer metformin or the insulin-lowering agent diazoxide with the rationale that pharmacological improvement of the primary defect would alleviate the secondary symptoms. We show that improving insulin sensitivity with metformin does not normalize hyperinsulinemia, whereas lowering insulin levels with diazoxide improves insulin sensitivity. Taken together, these results suggest that hyperinsulinemia precedes insulin resistance in beta-cell leptin receptor-deficient mice, with insulin resistance developing as a secondary consequence of excessive insulin secretion. Therefore, pancreatic beta-cell leptin receptor-deficient mice may represent a model of obesity-associated insulin resistance that is initiated by hyperinsulinemia.
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Affiliation(s)
- Sarah L Gray
- Laboratory of Molecular and Cellular Medicine, Department of Cellular and Physiological Sciences, Life Sciences Institute, 2350 Health Sciences Mall, University of British Columbia, Vancouver, British Columbia, Canada V6T 1Z3
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Abstract
Congenital hyperinsulinism is a leading cause of severe hypoglycaemia in the newborn period. There are two (diffuse and focal) histological subtypes of congenital hyperinsulinism. The diffuse form affects the entire pancreas and if medically unresponsive will require a near total (95%-98%) pancreatectomy. The focal form affects only a small region of the pancreas (with the rest of the pancreas being normal in endocrine and exocrine function) and only requires a limited pancreatectomy. This limited section of the focal lesion has the potential for curing the patient. Thus the pre-operative differentiation of these two subgroups is extremely important. Recent advances in Fluorine-18-L-dihydroxyphenylalanine positron emission tomography ((18)F-DOPA PET/CT) have radically changed the clinical approach to patient with congenital hyperinsulinism. In most patients this novel imaging technique is able to offer precise pre-operative localisation of the focal lesion, thus guiding the extent of surgical resection.
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Affiliation(s)
- Dunia Ismail
- Clinical and Molecular Genetics Unit, The Developmental Endocrinology Research Group, Institute of Child Health, University College London, Great Ormond Street Hospital for Children NHS Trust, 30 Guilford Street, London, WC1N 1EH, UK
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Abstract
Hyperinsulinemic hypoglycemia is a recently described complication of Roux-en-Y gastric bypass (RYGB). We hypothesized that glucagon administration would help maintain normal postprandial plasma glucose concentrations by stimulating hepatic glucose output, and if so, represent a new therapeutic option for postbypass hypoglycemia. In this study, we compared the insulin and glycemic response to a mixed meal with and without concomitant glucagon infusion in a patient with severe recurrent hypoglycemia after RYGB. Although effective in transiently raising postprandial plasma glucose values, glucagon infusion was also associated with higher insulin concentrations, and failed to prevent symptomatic hypoglycemia. This case demonstrates that glucagon may have limited clinical utility in the treatment of post-RYGB hyperinsulinemic hypoglycemia.
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Affiliation(s)
- Florencia Halperin
- Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Mary E. Patti
- Joslin Diabetes Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Allison B. Goldfine
- Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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