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Rasmussen AG, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Rasmussen AH, Mortensen MB, Christesen HT. The difficult management of persistent, non-focal congenital hyperinsulinism: A retrospective review from a single, tertiary center. Pediatr Diabetes 2020; 21:441-455. [PMID: 31997554 DOI: 10.1111/pedi.12989] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 11/14/2019] [Accepted: 01/13/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/OBJECTIVE Congenital hyperinsulinism (CHI) is a rare, heterogeneous disease with transient or persistent hypoglycemia. Histologically, focal, diffuse, and atypical forms of CHI exist, and at least 11 disease-causing genes have been identified. METHODS We retrospectively evaluated the treatment and outcome of a cohort of 40 patients with non-focal, persistent CHI admitted to the International Hyperinsulinism Center, Denmark, from January 2000 to May 2017. RESULTS Twenty-two patients (55%) could not be managed with medical monotherapy (diazoxide or octreotide) and six (15%) patients developed severe potential side effects to medication. Surgery was performed in 17 (43%) patients with resection of 66% to 98% of the pancreas. Surgically treated patients had more frequently KATP -channel gene mutations (surgical treatment 12/17 vs conservative treatment 6/23, P = .013), highly severe disease (15/17 vs 13/23, P = .025) and clinical onset <30 days of age (15/17 vs 10/23, P = .004). At last follow-up at median 5.3 (range: 0.3-31.3) years of age, 31/40 (78%) patients still received medical treatment, including 12/17 (71%) after surgery. One patient developed diabetes after a 98% pancreatic resection. Problematic treatment status was seen in 7/40 (18%). Only 8 (20%) had clinical remission (three spontaneous, five after pancreatic surgery). Neurodevelopmental impairment (n = 12, 30%) was marginally associated with disease severity (P = .059). CONCLUSIONS Persistent, non-focal CHI remains difficult to manage. Neurological impairment in 30% suggests a frequent failure of prompt and adequate treatment. A high rate of problematic treatment status at follow-up demonstrates an urgent need for new medical treatment modalities.
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Affiliation(s)
- Amalie G Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Maria Melikian
- Department of Pediatric Endocrinology, Endrocrine Research Center, Moscow, Russia
| | - Evgenia Globa
- Department of Pediatric Endocrinology, Ukrainian Research Center of Endocrine Surgery, Kyiv, Ukraine
| | - Sönke Detlefsen
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Annett H Rasmussen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark
| | - Michael B Mortensen
- OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark.,Department of Surgery, Odense University Hospital, Odense, Denmark
| | - Henrik T Christesen
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,OPAC, Odense Pancreas Center, Odense University Hospital, Odense, Denmark
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Sikimic J, Hoffmeister T, Gresch A, Kaiser J, Barthlen W, Wolke C, Wieland I, Lendeckel U, Krippeit-Drews P, Düfer M, Drews G. Possible New Strategies for the Treatment of Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2020; 11:545638. [PMID: 33193079 PMCID: PMC7653201 DOI: 10.3389/fendo.2020.545638] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 10/02/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Congenital hyperinsulinism (CHI) is a rare disease characterized by persistent hypoglycemia as a result of inappropriate insulin secretion, which can lead to irreversible neurological defects in infants. Poor efficacy and strong adverse effects of the current medications impede successful treatment. The aim of the study was to investigate new approaches to silence β-cells and thus attenuate insulin secretion. RESEARCH DESIGN AND METHODS In the scope of our research, we tested substances more selective and more potent than the gold standard diazoxide that also interact with neuroendocrine ATP-sensitive K+ (KATP) channels. Additionally, KATP channel-independent targets as Ca2+-activated K+ channels of intermediate conductance (KCa3.1) and L-type Ca2+ channels were investigated. Experiments were performed using human islet cell clusters isolated from tissue of CHI patients (histologically classified as pathological) and islet cell clusters obtained from C57BL/6N (WT) or SUR1 knockout (SUR1-/-) mice. The cytosolic Ca2+ concentration ([Ca2+]c) was used as a parameter for the pathway regulated by electrical activity and was determined by fura-2 fluorescence. The mitochondrial membrane potential (ΔΨ) was determined by rhodamine 123 fluorescence and single channel currents were measured by the patch-clamp technique. RESULTS The selective KATP channel opener NN414 (5 µM) diminished [Ca2+]c in isolated human CHI islet cell clusters and WT mouse islet cell clusters stimulated with 10 mM glucose. In islet cell clusters lacking functional KATP channels (SUR1-/-) the drug was without effect. VU0071063 (30 µM), another KATP channel opener considered to be selective, lowered [Ca2+]c in human CHI islet cell clusters. The compound was also effective in islet cell clusters from SUR1-/- mice, showing that [Ca2+]c is influenced by additional effects besides KATP channels. Contrasting to NN414, the drug depolarized ΔΨ in murine islet cell clusters pointing to severe interference with mitochondrial metabolism. An opener of KCa3.1 channels, DCEBIO (100 µM), significantly decreased [Ca2+]c in SUR1-/- and human CHI islet cell clusters. To target L-type Ca2+ channels we tested two already approved drugs, dextromethorphan (DXM) and simvastatin. DXM (100 µM) efficiently diminished [Ca2+]c in stimulated human CHI islet cell clusters as well as in stimulated SUR1-/- islet cell clusters. Similar effects on [Ca2+]c were observed in experiments with simvastatin (7.2 µM). CONCLUSIONS NN414 seems to provide a good alternative to the currently used KATP channel opener diazoxide. Targeting KCa3.1 channels by channel openers or L-type Ca2+ channels by DXM or simvastatin might be valuable approaches for treatment of CHI caused by mutations of KATP channels not sensitive to KATP channel openers.
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Affiliation(s)
- Jelena Sikimic
- Department of Pharmacology, Institute of Pharmacy, University of Tübingen, Tübingen, Germany
| | - Theresa Hoffmeister
- Department of Pharmacology, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Münster, Germany
| | - Anne Gresch
- Department of Pharmacology, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Münster, Germany
| | - Julia Kaiser
- Department of Pharmacology, Institute of Pharmacy, University of Tübingen, Tübingen, Germany
| | - Winfried Barthlen
- Department of Pediatric Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Carmen Wolke
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald, Germany
| | - Ilse Wieland
- Institute of Human Genetics, University Hospital Magdeburg, Magdeburg, Germany
| | - Uwe Lendeckel
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald, Germany
| | - Peter Krippeit-Drews
- Department of Pharmacology, Institute of Pharmacy, University of Tübingen, Tübingen, Germany
- *Correspondence: Peter Krippeit-Drews,
| | - Martina Düfer
- Department of Pharmacology, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Münster, Germany
| | - Gisela Drews
- Department of Pharmacology, Institute of Pharmacy, University of Tübingen, Tübingen, Germany
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Bendix J, Laursen MG, Mortensen MB, Melikian M, Globa E, Detlefsen S, Rasmussen L, Petersen H, Brusgaard K, Christesen HT. Intraoperative Ultrasound: A Tool to Support Tissue-Sparing Curative Pancreatic Resection in Focal Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2018; 9:478. [PMID: 30186238 PMCID: PMC6113400 DOI: 10.3389/fendo.2018.00478] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/02/2018] [Indexed: 12/11/2022] Open
Abstract
Background: Focal congenital hyperinsulinism (CHI) may be cured by resection of the focal, but often non-palpable, pancreatic lesion. The surgical challenge is to minimize removal of normal pancreatic tissue. Aim: To evaluate the results of intraoperative ultrasound-guided, tissue-sparing pancreatic resection in CHI patients at an international expert center. Methods: Retrospective study of CHI patients treated at Odense University Hospital, Denmark, between January 2010 and March 2017. Results: Of 62 consecutive patients with persistent CHI, 24 (39%) had focal CHI by histology after surgery. All patients had a paternal ABCC8 or KCNJ11 mutation and a focal lesion by 18F-DOPA-PET/CT. Intraoperative ultrasound localized the focal lesion in 16/20 patients (sensitivity 0.80), including one ectopic lesion in the duodenal wall. Intraoperative ultrasound showed no focal lesion in 11/11 patients with diffuse CH (specificity 1.0). The positive predictive value for focal histology was 1.0, negative predictive value 0.73. Tissue-sparing pancreatic resection (focal lesion enucleation, local resection of tail or uncinate process) was performed in 67% (n = 16). In 11/12 having tissue-sparing resection and intraoperative ultrasound, the location of the focal lesion was exactly identified. Eight patients had resection of the pancreatic head or head/body, four with Roux-en-Y, three with pancreatico-gastrostomy and one without reconstruction. None had severe complications to surgery. Cure of hypoglycaemia was seen in all patients after one (n = 21) or two (n = 3) pancreatic resections. Conclusion: In focal CHI, tissue-sparing pancreatic resection was possible in 67%. Intraoperative ultrasound was a helpful supplement to the mandatory use of genetics, preoperative 18F-DOPA-PET/CT and intraoperative frozen sections.
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Affiliation(s)
- Julie Bendix
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette G. Laursen
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Michael B. Mortensen
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
| | - Maria Melikian
- Department of Paediatric Endocrinology, Endocrine Research Centre, Moscow, Russia
| | - Evgenia Globa
- Department of Paediatric Endocrinology, Ukrainian Centre of Endocrine Surgery, Kiev, Ukraine
| | - Sönke Detlefsen
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- Department of Pathology, Odense University Hospital, Odense, Denmark
| | - Lars Rasmussen
- Department of Surgery, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
| | - Henrik Petersen
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Klaus Brusgaard
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- Department of Clinical Genetics, Odense University Hospital, Odense, Denmark
| | - Henrik T. Christesen
- Department of Paediatrics, Odense University Hospital, Odense, Denmark
- OPAC, Odense Pancreas Centre, Odense University Hospital, Odense, Denmark
- *Correspondence: Henrik T. Christesen
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Yorifuji T, Horikawa R, Hasegawa T, Adachi M, Soneda S, Minagawa M, Ida S, Yonekura T, Kinoshita Y, Kanamori Y, Kitagawa H, Shinkai M, Sasaki H, Nio M. Clinical practice guidelines for congenital hyperinsulinism. Clin Pediatr Endocrinol 2017; 26:127-152. [PMID: 28804205 PMCID: PMC5537210 DOI: 10.1297/cpe.26.127] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/08/2017] [Indexed: 12/11/2022] Open
Abstract
Congenital hyperinsulinism is a rare condition, and following recent advances in
diagnosis and treatment, it was considered necessary to formulate evidence-based clinical
practice guidelines reflecting the most recent progress, to guide the practice of
neonatologists, pediatric endocrinologists, general pediatricians, and pediatric surgeons.
These guidelines cover a range of aspects, including general features of congenital
hyperinsulinism, diagnostic criteria and tools for diagnosis, first- and second-line
medical treatment, criteria for and details of surgical treatment, and future
perspectives. These guidelines were generated as a collaborative effort between The
Japanese Society for Pediatric Endocrinology and The Japanese Society of Pediatric
Surgeons, and followed the official procedures of guideline generation to identify
important clinical questions, perform a systematic literature review (April 2016), assess
the evidence level of each paper, formulate the guidelines, and obtain public
comments.
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Affiliation(s)
- Tohru Yorifuji
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | | | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Shun Soneda
- Department of Pediatrics, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | - Shinobu Ida
- Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Takeo Yonekura
- Department of Pediatric Surgery, Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Kanamori
- Department of Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Hideyuki Sasaki
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
| | - Masaki Nio
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
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Han B, Newbould M, Batra G, Cheesman E, Craigie RJ, Mohamed Z, Rigby L, Padidela R, Skae M, Mironov A, Starborg T, Kadler KE, Cosgrove KE, Banerjee I, Dunne MJ. Enhanced Islet Cell Nucleomegaly Defines Diffuse Congenital Hyperinsulinism in Infancy but Not Other Forms of the Disease. Am J Clin Pathol 2016; 145:757-68. [PMID: 27334808 PMCID: PMC4922485 DOI: 10.1093/ajcp/aqw075] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To quantify islet cell nucleomegaly in controls and tissues obtained from patients with congenital hyperinsulinism in infancy (CHI) and to examine the association of nucleomegaly with proliferation. METHODS High-content analysis of histologic sections and serial block-face scanning electron microscopy were used to quantify nucleomegaly. RESULTS Enlarged islet cell nuclear areas were 4.3-fold larger than unaffected nuclei, and the mean nuclear volume increased to approximately threefold. Nucleomegaly was a normal feature of pediatric islets and detected in the normal regions of the pancreas from patients with focal CHI. The incidence of nucleomegaly was highest in diffuse CHI (CHI-D), with more than 45% of islets containing two or more affected cells. While in CHI-D nucleomegaly was negatively correlated with cell proliferation, in all other cases, there was a positive correlation. CONCLUSIONS Increased incidence of nucleomegaly is pathognomonic for CHI-D, but these cells are nonproliferative, suggesting a novel role in the pathobiology of this condition.
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Affiliation(s)
- Bing Han
- From the Faculty of Life Sciences, University of Manchester, Manchester, UK
| | | | | | | | | | - Zainab Mohamed
- From the Faculty of Life Sciences, University of Manchester, Manchester, UK Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust (CMFT), Manchester, UK
| | - Lindsey Rigby
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust (CMFT), Manchester, UK
| | - Raja Padidela
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust (CMFT), Manchester, UK
| | - Mars Skae
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust (CMFT), Manchester, UK
| | - Aleksandr Mironov
- From the Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Tobias Starborg
- From the Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Karl E Kadler
- From the Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Karen E Cosgrove
- From the Faculty of Life Sciences, University of Manchester, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester University Hospitals NHS Foundation Trust (CMFT), Manchester, UK
| | - Mark J Dunne
- From the Faculty of Life Sciences, University of Manchester, Manchester, UK
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Yorifuji T, Masue M, Nishibori H. Congenital hyperinsulinism: global and Japanese perspectives. Pediatr Int 2014; 56:467-76. [PMID: 24865345 DOI: 10.1111/ped.12390] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 05/12/2014] [Indexed: 12/12/2022]
Abstract
Over the past 20 years, there has been remarkable progress in the diagnosis and treatment of congenital hyperinsulinism (CHI). These advances have been supported by the understanding of the molecular mechanism and the development of diagnostic modalities to identify the focal form of ATP-sensitive potassium channel CHI. Many patients with diazoxide-unresponsive focal CHI have been cured by partial pancreatectomy without developing postsurgical diabetes mellitus. Important novel findings on the genetic basis of the other forms of CHI have also been obtained, and several novel medical treatments have been explored. However, the management of patients with CHI is still far from ideal. First, state-of-the-art treatment is not widely available worldwide. Second, it appears that the management strategy needs to be adjusted according to the patient's ethnic group. Third, optimal management of patients with the diazoxide-unresponsive, diffuse form of CHI is still insufficient and requires further improvement. In this review, we describe the current landscape of this disorder, discuss the racial disparity of CHI using Japanese patients as an example, and briefly note unanswered questions and unmet needs that should be addressed in the near future.
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Affiliation(s)
- Tohru Yorifuji
- Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan; Clinical Research Center, Osaka City General Hospital, Osaka, Japan; Department of Genetic Medicine, Osaka City General Hospital, Osaka, Japan
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Yorifuji T. Congenital hyperinsulinism: current status and future perspectives. Ann Pediatr Endocrinol Metab 2014; 19:57-68. [PMID: 25077087 PMCID: PMC4114053 DOI: 10.6065/apem.2014.19.2.57] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 04/14/2014] [Indexed: 11/25/2022] Open
Abstract
The diagnosis and treatment of congenital hyperinsulinism (CHI) have made a remarkable progress over the past 20 years and, currently, it is relatively rare to see patients who are left with severe psychomotor delay. The improvement was made possible by the recent developments in the understanding of the molecular and pathological basis of CHI. Known etiologies include inactivating mutations of the KATP channel genes (ABCC8 and KCNJ11) and HNF4A, HNF1A, HADH, and UCP2 or activating mutations of GLUD1, GCK, and SLC16A1. The understanding of the focal form of KATP channel CHI and its detection by (18)F-fluoro-L-DOPA positron emission tomography have revolutionized the management of CHI, and many patients can be cured without postoperative diabetes mellitus. The incidence of the focal form appears to be higher in Asian countries; therefore, the establishment of treatment systems is even more important in this population. In addition to diazoxide or long-term subcutaneous infusion of octreotide or glucagon, long-acting octreotide or lanreotide have also been used successfully until spontaneous remission. Because of these medications, near-total pancreatectomy is less often performed even for the diazoxide-unresponsive diffuse form of CHI. Other promising medications include pasireotide, small-molecule correctors such as sulfonylurea or carbamazepine, GLP1 receptor antagonists, or mammalian target of rapamycin inhibitors. Unsolved questions in this field include the identification of the remaining genes responsible for CHI, the mechanisms leading to transient CHI, and the mechanisms responsible for the spontaneous remission of CHI. This article reviews recent developments and hypothesis regarding these questions.
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Affiliation(s)
- Tohru Yorifuji
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
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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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Yorifuji T, Kawakita R, Hosokawa Y, Fujimaru R, Matsubara K, Aizu K, Suzuki S, Nagasaka H, Nishibori H, Masue M. Efficacy and safety of long-term, continuous subcutaneous octreotide infusion for patients with different subtypes of KATP-channel hyperinsulinism. Clin Endocrinol (Oxf) 2013; 78:891-7. [PMID: 23067144 DOI: 10.1111/cen.12075] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 07/31/2012] [Accepted: 10/10/2012] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To evaluate the efficacy of long-term, continuous, subcutaneous octreotide infusion for congenital hyperinsulinism caused by mutations in the KATP-channel genes, KCNJ11 and ABCC8. PATIENTS Fifteen Japanese patients with diazoxide-unresponsive, KATP-channel hyperinsulinism. METHODS Molecular diagnoses were made by sequencing and multiple ligation-dependent probe amplification analysis. In patients with paternally inherited, monoallelic mutations, 18F-DOPA PET scans were performed to determine the location of the lesion. The patients were treated with continuous, subcutaneous octreotide infusion at a dosage of up to 25 μg/kg/day, using an insulin pump to maintain blood glucose levels higher than 3.33 mmol/l. Additional treatments (IV glucose, glucagon or enteral feeding) were administered as needed. The efficacy of the treatment was assessed in patients who received octreotide for 4 months to 5.9 years. RESULTS Three patients had biallelic mutations, and 12 had monoallelic, paternally inherited mutations. Four patients with monoallelic mutations showed diffuse 18F-DOPA uptake, whereas seven patients showed focal uptake. Octreotide was effective in all the patients. The patients with biallelic mutations required a higher dosage (17-25 μg/kg/day), and two patients required additional treatments. By contrast, the patients with monoallelic mutations required a lower dosage (0.5-21 μg/kg/day) irrespective of the PET results and mostly without additional treatments. Treatment was discontinued in three patients at 2.5, 3.3 and 5.9 years of age, without psychomotor delay. Except for growth deceleration at a higher dosage, no significant adverse effects were noted. CONCLUSIONS Long-term, continuous, subcutaneous octreotide infusion is a feasible alternative to surgery especially for patients with monoallelic KATP-channel mutations.
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Affiliation(s)
- Tohru Yorifuji
- Department of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan.
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