1
|
Kaiser JR, Amatya S, Burke RJ, Corr TE, Darwish N, Gandhi CK, Gasda A, Glass KM, Kresch MJ, Mahdally SM, McGarvey MT, Mola SJ, Murray YL, Nissly K, Santiago-Aponte NM, Valencia JC, Palmer TW. Proposed Screening for Congenital Hyperinsulinism in Newborns: Perspective from a Neonatal-Perinatal Medicine Group. J Clin Med 2024; 13:2953. [PMID: 38792494 PMCID: PMC11122587 DOI: 10.3390/jcm13102953] [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: 03/12/2024] [Revised: 05/14/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
This perspective work by academic neonatal providers is written specifically for the audience of newborn care providers and neonatologists involved in neonatal hypoglycemia screening. Herein, we propose adding a screen for congenital hyperinsulinism (CHI) by measuring glucose and ketone (i.e., β-hydroxybutyrate (BOHB)) concentrations just prior to newborn hospital discharge and as close to 48 h after birth as possible, at the same time that the mandated state Newborn Dried Blood Spot Screen is obtained. In the proposed protocol, we do not recommend specific metabolite cutoffs, as our primary objective is to simply highlight the concept of screening for CHI in newborns to newborn caregivers. The premise for our proposed screen is based on the known effect of hyperinsulinism in suppressing ketogenesis, thereby limiting ketone production. We will briefly discuss genetic CHI, other forms of neonatal hypoglycemia, and their shared mechanisms; the mechanism of insulin regulation by functional pancreatic islet cell membrane KATP channels; adverse neurodevelopmental sequelae and brain injury due to missing or delaying the CHI diagnosis; the principles of a good screening test; how current neonatal hypoglycemia screening programs do not fulfill the criteria for being effective screening tests; and our proposed algorithm for screening for CHI in newborns.
Collapse
Affiliation(s)
- Jeffrey R. Kaiser
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
- Department of Obstetrics and Gynecology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Shaili Amatya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Rebecca J. Burke
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Tammy E. Corr
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Nada Darwish
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Chintan K. Gandhi
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Adrienne Gasda
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Kristen M. Glass
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Mitchell J. Kresch
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Sarah M. Mahdally
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Maria T. McGarvey
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Sara J. Mola
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Yuanyi L. Murray
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Katie Nissly
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Nanyaly M. Santiago-Aponte
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Jazmine C. Valencia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| | - Timothy W. Palmer
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA; (S.A.); (R.J.B.); (T.E.C.); (N.D.); (C.K.G.); (A.G.); (K.M.G.); (M.J.K.); (S.M.M.); (M.T.M.); (S.J.M.); (Y.L.M.); (K.N.); (N.M.S.-A.); (J.C.V.); (T.W.P.)
| |
Collapse
|
2
|
Dinu D, Hagan JL, Rozance PJ. Variability in Diagnosis and Management of Hypoglycemia in Neonatal Intensive Care Unit. Am J Perinatol 2024. [PMID: 38565171 DOI: 10.1055/s-0044-1785491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Hypoglycemia, the most common metabolic derangement in the newborn period remains a contentious issue, not only due to various numerical definitions, but also due to limited therapeutical options which either lack evidence to support their efficacy or are increasingly recognized to lead to adverse reactions in this population. This study aimed to investigate neonatologists' current attitudes in diagnosing and managing transient and persistent hypoglycemia in newborns admitted to the Neonatal Intensive Care Unit (NICU). METHODS A web-based electronic survey which included 34 questions and a clinical vignette was sent to U.S. neonatologists. RESULTS There were 246 survey responses with most respondents using local protocols to manage this condition. The median glucose value used as the numerical definition of hypoglycemia in first 48 hours of life (HOL) for symptomatic and asymptomatic term infants and preterm infants was 45 mg/dL (2.5 mmol/L; 25-60 mg/dL; 1.4-3.3 mmol/L), while after 48 HOL the median value was 50 mg/dL (2.8 mmol/L; 30-70 mg/dL; 1.7-3.9 mmol/L). There were various approaches used to manage transient and persistent hypoglycemia that included dextrose gel, increasing caloric content of the feeds using milk fortifiers, using continuous feedings, formula or complex carbohydrates, and use of various medications such as diazoxide, glucocorticoids, and glucagon. CONCLUSION There is still large variability in current practices related to hypoglycemia. Further research is needed not only to provide evidence to support the values used as a numerical definition for hypoglycemia, but also on the efficacy of current strategies used to manage this condition. KEY POINTS · Numerical definition of glucose remains variable.. · Strategies managing transient and persistent hypoglycemia are diverse.. · There is a need for further research to investigate efficacy of various treatment options..
Collapse
Affiliation(s)
- Daniela Dinu
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joseph L Hagan
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Paul J Rozance
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
3
|
Liberatore RDR, Monteiro ICM, Pileggi FDO, Canesin WC, Sbragia L. Congenital hyperinsulinism and surgical outcome in a single tertiary center in Brazil. J Pediatr (Rio J) 2024; 100:163-168. [PMID: 37866397 PMCID: PMC10943321 DOI: 10.1016/j.jped.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 10/24/2023] Open
Abstract
OBJECTIVE Congenital hyperinsulinism (CHI) is a heterogeneous genetic disease characterized by increased insulin secretion and causes persistent hypoglycemia in neonates and infants due to dysregulation of insulin secretion by pancreatic β cells. Babies with severe hypoglycemia and for whom medical treatment has been ineffective usually require surgical treatment with near-total pancreatectomy. To evaluate the clinical and surgical aspects affecting survival outcomes in babies diagnosed with CHI in a single tertiary care center. METHODS Retrospective Cohort study involving a single university tertiary center for the treatment of CHI. The authors study the demographics, clinical, laboratory, and surgical outcomes of this casuistic. RESULTS 61 % were female, 39 % male, Birth weight: 3576 g (±313); Age of onset of symptoms: from the 2nd hour of life to 28 days; Time between diagnosis and surgery ranged between 10 and 60 days; Medical clinical treatment, all patients received glucose solution with a continuous glucose infusion and diazoxide. 81 % of the patients used corticosteroids, 77 %. thiazide, 72 % octreotide, 27 % nifedipine; Neurological sequelae during development and growth: 54 % had some degree of delay in neuropsychomotor development, 27 % obesity. Surgery was performed open in 6 and 12 minimally invasive surgery (MIS). HISTOPATHOLOGY 2 focal and 16 diffuse, Length of stay (days) was lower in MIS (p < 0.05). Survival was 100 %. CONCLUSIONS CHI is a rare and difficult-to-manage tumor that must be performed in a multidisciplinary and tertiary center. Most surgical results are good and the laparoscopic approach to disease has been the best choice for patients.
Collapse
Affiliation(s)
- Raphael Del Roio Liberatore
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Endocrinologia Pediátrica e Departamento de Puericultura e Pediatria, Ribeirão Preto, SP, Brazil
| | - Isabella Christina Mazzaro Monteiro
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Endocrinologia Pediátrica e Departamento de Puericultura e Pediatria, Ribeirão Preto, SP, Brazil
| | - Flavio de Oliveira Pileggi
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Cirurgia Pediátrica, Departamento de Cirurgia e Anatomia, Ribeirão Preto, SP, Brazil
| | - Wellen Cristina Canesin
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Cirurgia Pediátrica, Departamento de Cirurgia e Anatomia, Ribeirão Preto, SP, Brazil
| | - Lourenço Sbragia
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Divisão de Cirurgia Pediátrica, Departamento de Cirurgia e Anatomia, Ribeirão Preto, SP, Brazil.
| |
Collapse
|
4
|
Lee CT, Tsai WH, Chang CC, Chen PC, Fann CSJ, Chang HK, Liu SY, Wu MZ, Chiu PC, Hsu WM, Yang WS, Lai LP, Tsai WY, Yang SB, Chen PL. Genotype-phenotype correlation in Taiwanese children with diazoxide-unresponsive congenital hyperinsulinism. Front Endocrinol (Lausanne) 2023; 14:1283907. [PMID: 38033998 PMCID: PMC10687152 DOI: 10.3389/fendo.2023.1283907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Objective Congenital hyperinsulinism (CHI) is a group of clinically and genetically heterogeneous disorders characterized by dysregulated insulin secretion. The aim of the study was to elucidate genetic etiologies of Taiwanese children with the most severe diazoxide-unresponsive CHI and analyze their genotype-phenotype correlations. Methods We combined Sanger with whole exome sequencing (WES) to analyze CHI-related genes. The allele frequency of the most common variant was estimated by single-nucleotide polymorphism haplotype analysis. The functional effects of the ATP-sensitive potassium (KATP) channel variants were assessed using patch clamp recording and Western blot. Results Nine of 13 (69%) patients with ten different pathogenic variants (7 in ABCC8, 2 in KCNJ11 and 1 in GCK) were identified by the combined sequencing. The variant ABCC8 p.T1042QfsX75 identified in three probands was located in a specific haplotype. Functional study revealed the human SUR1 (hSUR1)-L366F KATP channels failed to respond to intracellular MgADP and diazoxide while hSUR1-R797Q and hSUR1-R1393C KATP channels were defective in trafficking. One patient had a de novo dominant mutation in the GCK gene (p.I211F), and WES revealed mosaicism of this variant from another patient. Conclusion Pathogenic variants in KATP channels are the most common underlying cause of diazoxide-unresponsive CHI in the Taiwanese cohort. The p.T1042QfsX75 variant in the ABCC8 gene is highly suggestive of a founder effect. The I211F mutation in the GCK gene and three rare SUR1 variants associated with defective gating (p.L366F) or traffic (p.R797Q and p.R1393C) KATP channels are also associated with the diazoxide-unresponsive phenotype.
Collapse
Affiliation(s)
- Cheng-Ting Lee
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Hao Tsai
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | | | - Pei-Chun Chen
- Department of Physiology, National Cheng-Kung University, Tainan, Taiwan
| | | | - Hsueh-Kai Chang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Shih-Yao Liu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Mu-Zon Wu
- Department of Pathology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Pao-Chin Chiu
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wen-Ming Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wei-Shiung Yang
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Medical Genomics and Proteomics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ling-Ping Lai
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Yu Tsai
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shi-Bing Yang
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Pei-Lung Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- Graduate Institute of Medical Genomics and Proteomics, National Taiwan University College of Medicine, Taipei, Taiwan
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
5
|
Hopkins JJ, Childs AJ, Houghton JAL, Hewat TI, Atapattu N, Johnson MB, Patel KA, Laver TW, Flanagan SE. Hyperinsulinemic Hypoglycemia Diagnosed in Childhood Can Be Monogenic. J Clin Endocrinol Metab 2023; 108:680-687. [PMID: 36239000 PMCID: PMC9931180 DOI: 10.1210/clinem/dgac604] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/05/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Congenital hyperinsulinism (HI) is characterized by inappropriate insulin secretion despite low blood glucose. Persistent HI is often monogenic, with the majority of cases diagnosed in infancy. Less is known about the contribution of monogenic forms of disease in those presenting in childhood. OBJECTIVE We investigated the likelihood of finding a genetic cause in childhood-onset HI and explored potential factors leading to later age at presentation of disease. METHODS We screened known disease-causing genes in 1848 individuals with HI, referred for genetic testing as part of routine clinical care. Individuals were classified as infancy-onset (diagnosed with HI < 12 months of age) or childhood-onset (diagnosed at age 1-16 years). We assessed clinical characteristics and the genotypes of individuals with monogenic HI diagnosed in childhood to gain insights into the later age at diagnosis of HI in these children. RESULTS We identified the monogenic cause in 24% (n = 42/173) of the childhood-onset HI cohort; this was significantly lower than the proportion of genetic diagnoses in infancy-onset cases (74.5% [n = 1248/1675], P < 0.00001). Most (75%) individuals with genetically confirmed childhood-onset HI were diagnosed before 2.7 years, suggesting these cases represent the tail end of the normal distribution in age at diagnosis. This is supported by the finding that 81% of the variants identified in the childhood-onset cohort were detected in those diagnosed in infancy. CONCLUSION We have shown that monogenic HI is an important cause of hyperinsulinism presenting outside of infancy. Genetic testing should be considered in children with persistent hyperinsulinism, regardless of age at diagnosis.
Collapse
Affiliation(s)
| | | | - Jayne A L Houghton
- The Genomics Laboratory, Royal Devon University Healthcare NHS foundation Trust, Exeter EX2 5DW, UK
| | - Thomas I Hewat
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Navoda Atapattu
- Paediatric Endocrinology, Lady Ridgeway Hospital, Colombo 00800, Sri Lanka
| | - Matthew B Johnson
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Kashyap A Patel
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
- The Genomics Laboratory, Royal Devon University Healthcare NHS foundation Trust, Exeter EX2 5DW, UK
| | - Thomas W Laver
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter EX2 5DW, UK
| | - Sarah E Flanagan
- Correspondence: Dr. Sarah E. Flanagan, Associate Professor in Genomic Medicine, RILD Building, University of Exeter Medical School, Barrack Road, Exeter EX2 5DW, UK.
| |
Collapse
|
6
|
Diazoxide for Neonatal Hyperinsulinemic Hypoglycemia and Pulmonary Hypertension. CHILDREN (BASEL, SWITZERLAND) 2022; 10:children10010005. [PMID: 36670556 PMCID: PMC9856357 DOI: 10.3390/children10010005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
Hypoglycemia in neonates is associated with long-term neurodevelopmental effects. Hyperinsulinemic hypoglycemia (HH) is the most common cause of persistent hypoglycemia in neonatal intensive care units. Diazoxide is the only medication that is currently recommended for treatment of HH in neonates. However, the use of diazoxide in neonates is associated with pulmonary hypertension as an adverse effect. In this article, we review the literature on the mechanism of action and adverse effects with the use of diazoxide in neonatal hyperinsulinism. We then present a case series of neonates treated with diazoxide in our neonatal intensive care unit over a 5-year period. Among 23 neonates who received diazoxide, 4 developed pulmonary hypertension and 1 died. All infants who developed pulmonary hypertension were born preterm at less than 36 weeks gestation and had pre-existing risk factors for pulmonary hypertension. HH in preterm neonates, with pre-existing pulmonary hypertension or with risk factors for pulmonary hypertension requires thoughtful management.
Collapse
|
7
|
Giri D, Hawton K, Senniappan S. Congenital hyperinsulinism: recent updates on molecular mechanisms, diagnosis and management. J Pediatr Endocrinol Metab 2022; 35:279-296. [PMID: 34547194 DOI: 10.1515/jpem-2021-0369] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/30/2021] [Indexed: 12/20/2022]
Abstract
Congenital hyperinsulinism (CHI) is a rare disease characterized by an unregulated insulin release, leading to hypoglycaemia. It is the most frequent cause of persistent and severe hypoglycaemia in the neonatal period and early childhood. Mutations in 16 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, KCNQ1, CACNA1D, FOXA2, EIF2S3, PGM1 and PMM2) that are involved in regulating the insulin secretion from pancreatic β-cells have been described to be responsible for the underlying molecular mechanisms of CHI. CHI can also be associated with specific syndromes and can be secondary to intrauterine growth restriction (IUGR), maternal diabetes, birth asphyxia, etc. It is important to diagnose and promptly initiate appropriate management as untreated hypoglycaemia can be associated with significant neurodisability. CHI can be histopathologically classified into diffuse, focal and atypical forms. Advances in molecular genetics, imaging techniques (18F-fluoro-l-dihydroxyphenylalanine positron emission tomography/computed tomography scanning), novel medical therapies and surgical advances (laparoscopic pancreatectomy) have changed the management and improved the outcome of patients with CHI. This review article provides an overview of the background, clinical presentation, diagnosis, molecular genetics and therapy for children with different forms of CHI.
Collapse
Affiliation(s)
- Dinesh Giri
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK.,University of Bristol, Bristol, UK
| | - Katherine Hawton
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | |
Collapse
|
8
|
Martino M, Sartorelli J, Gragnaniello V, Burlina A. Congenital hyperinsulinism in clinical practice: From biochemical pathophysiology to new monitoring techniques. Front Pediatr 2022; 10:901338. [PMID: 36210928 PMCID: PMC9538154 DOI: 10.3389/fped.2022.901338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Congenital hyperinsulinism comprises a group of diseases characterized by a persistent hyperinsulinemic hypoglycemia, due to mutation in the genes involved in the regulation of insulin secretion. The severity and the duration of hypoglycemic episodes, primarily in the neonatal period, can lead to neurological impairment. Detecting blood sugar is relatively simple but, unfortunately, symptoms associated with hypoglycemia may be non-specific. Research in this field has led to novel insight in diagnosis, monitoring and treatment, leading to a better neurological outcome. Given the increased availability of continuous glucose monitoring systems that allow glucose level recognition in a minimally invasive way, monitoring the glycemic trend becomes easier and there are more possibilities of a better follow-up of patients. We aim to provide an overview of new available technologies and new discoveries and their potential impact on clinical practice, convinced that only with a better awareness of the disease and available tools we can have a better impact on CHI diagnosis, prevention and clinical sequelae.
Collapse
Affiliation(s)
| | | | - Vincenza Gragnaniello
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padua, Italy
| | - Alberto Burlina
- Division of Inborn Metabolic Disease, Department of Pediatrics, University Hospital Padua, Padua, Italy
| |
Collapse
|
9
|
Falzone N, Harrington J. Clinical Predictors of Transient versus Persistent Neonatal Hyperinsulinism. Horm Res Paediatr 2021; 93:297-303. [PMID: 33197914 DOI: 10.1159/000511139] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 08/12/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Hyperinsulinism (HI), the most common neonatal cause of persistent hypoglycemia, can be associated with prolonged hospitalizations and risk for long-term neurological sequelae. Rapid identification of transient versus persistent forms of HI is crucial to optimize management. OBJECTIVES The aims of the study were to assess the ability of clinical and biochemical features at presentation to predict transient versus persistent HI, and to evaluate differences in hospital outcomes. METHODS This study is a retrospective review of 79 infants with HI admitted to the Hospital for Sick Children, Toronto, from 2012 to 2017. Patients were classified into 3 groups: transient and the 2 persistent forms, diazoxide responsive and diazoxide unresponsive (DU). RESULTS Infants with birth weight >90th percentile had an 8-fold increased risk of having a persistent form of HI (OR 8.8, 95% CI 2.5-30) and a 21-fold increased risk of having a DU form of HI (OR 21.1, 95% CI 4.9-91.8). The majority of children with transient HI and a birth weight >90th percentile were born to mothers with gestational diabetes. There were no other useful clinical or biochemical presenting features that differentiated the groups. There were significant differences in outcome measures, with the DU children more likely to require gastrostomy tube insertion and have an extended length of hospital admission. CONCLUSION A higher birth weight in the absence of maternal gestational diabetes is highly associated with a persistent form of HI. Given the marked difference in clinical outcomes between groups, expedited genetic testing should be considered in infants with this presentation to inform clinical management.
Collapse
Affiliation(s)
- Nicole Falzone
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Harrington
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada, .,Department of Pediatrics, Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada,
| |
Collapse
|
10
|
Clinical and genetic characteristics of patients with congenital hyperinsulinism in 21 non-consanguineous families from Serbia. Eur J Pediatr 2021; 180:2815-2821. [PMID: 33770274 DOI: 10.1007/s00431-021-04051-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/07/2021] [Accepted: 03/21/2021] [Indexed: 10/21/2022]
Abstract
Persistent hypoglycaemia in newborns and infants is most commonly caused by congenital hyperinsulinism (CHI). Most CHI studies report outcomes in children from both consanguineous and non-consanguineous families which can affect the phenotype-genotype analysis. The aim of this study was to analyze characteristics of patients with CHI in 21 non-consanguineous families from Serbia. This retrospective cohort study included a total of 21 patients with CHI treated in the Mother and Child Healthcare Institute of Serbia during the past 20 years. The prevalence of macrosomia at birth was very low in our cohort (4.8%). Median age at presentation was 6 days, with seizures as the presenting symptom in 76% of patients. Only four patients (19%) were diazoxide unresponsive, and eventually underwent pancreatectomy. Genetic testing was performed in 15 patients and genetic diagnosis was confirmed in 60%, with all patients being heterozygous for detected mutations. The ABCC8 gene mutations were detected in 55.6%, GLUD1 in three patients (33.3%) with HIHA syndrome and one patient had HNF4A gene mutation and unusual prolonged hyperglycaemia lasting 6 days after diazoxide cessation. Neurodevelopmental deficits persisted in 33% of patients.Conclusion: This is the first study regarding CHI patients in Serbia. It suggests that in countries with low consanguinity rate, majority of CHI patients are diazoxide responsive. The most common mutations were heterozygous ABCC8, followed by GLUD1 and HNF4A mutations, suggesting the potential benefit of population-tailored genetic analysis approach, targeting the mutations causing CHI via dominant inheritance model in regions with low consanguinity rates. What is Known: • Persistent hypoglycaemia during infancy and early childhood is most commonly caused by congenital hyperinsulinism (CHI). • Consanguinity is a very important factor regarding the genetics and phenotype of CHI, increasing the risk of autosomal recessive genetic disorders, including the severe, diazoxide-unresponsive forms caused by recessive inactivating mutations in ABCC8 and KCNJ11. What is New: • Results of the present study which included CHI patients from 21 non-consanguineous families suggest that in countries with low consanguinity rates, majority of CHI patients can be diazoxide responsive, with most common mutations being heterozygous ABCC8, followed by GLUD1 and HNF4A mutations. • Unusually prolonged hyperglycaemic reaction to diazoxide treatment in a patient with HNF4A mutation was also described in the present study.
Collapse
|
11
|
Golson ML. Islet Epigenetic Impacts on β-Cell Identity and Function. Compr Physiol 2021; 11:1961-1978. [PMID: 34061978 DOI: 10.1002/cphy.c200004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The development and maintenance of differentiation is vital to the function of mature cells. Terminal differentiation is achieved by locking in the expression of genes essential for the function of those cells. Gene expression and its memory through generations of cell division is controlled by transcription factors and a host of epigenetic marks. In type 2 diabetes, β cells have altered gene expression compared to controls, accompanied by altered chromatin marks. Mutations, diet, and environment can all disrupt the implementation and preservation of the distinctive β-cell transcriptional signature. Understanding of the full complement of genomic control in β cells is still nascent. This article describes the known effects of histone marks and variants, DNA methylation, how they are regulated in the β cell, and how they affect cell-fate specification, maintenance, and lineage propagation. © 2021 American Physiological Society. Compr Physiol 11:1-18, 2021.
Collapse
Affiliation(s)
- Maria L Golson
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
12
|
Loh WJ, Dacay LM, Tan CSH, Ang SF, Yap F, Lim SC, Khoo J. Glucokinase activating mutation causing hypoglycaemia diagnosed late in adult who fasts for Ramadhan. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM210043. [PMID: 34184638 PMCID: PMC8240715 DOI: 10.1530/edm-21-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/25/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Activating mutation of glucokinase gene (GCK) causes resetting of insulin inhibition at a lower glucose threshold causing hyperinsulinaemic hypoglycaemia (GCK-HH). This is the first reported case who tolerated years of regular fasting during Ramadhan, presenting only with seizure and syncope now. We describe a case with GCK gene variant p.T65I diagnosed in a 51-year-old woman with hypoglycaemia unawareness even at glucose level of 1.6 mmol/L. Insulin and C-peptide levels during hypoglycaemia were suggestive of hyperinsulinism, but at a day after intravenous glucagon, hypoglycaemia occurred with low insulin and C-peptide levels, pointing against insulinoma as the underlying aetiology. Imaging studies of the pancreas and calcium arterial stimulation venous sampling were unremarkable. A review of old medical records revealed asymptomatic hypoglycaemia years ago. Genetic testing confirmed activating mutation of GCK. Hypoglycaemia was successfully controlled with a somatostatin analogue. This case highlights the importance of consideration of genetic causes of hypoglycaemia in adulthood, especially when imaging is uninformative. LEARNING POINTS Consider genetic causes of endogenous hyperinsulinism hypoglycaemia in adulthood, especially when imaging is uninformative. Late presentation of activating mutation of GCK can occur because of hypoglycaemia unawareness. Long-acting somatostatin analogue may be useful for the treatment of activating mutation of GCK causing hypoglycaemia. Depending on the glucose level when the blood was taken, and the threshold of glucose-stimulated insulin release (GSIR), the serum insulin and C-peptide levels may be raised (hyperinsulinaemic) or low (hypoinsulinaemic) in patients with activating mutation of GCK. Glucagon may be useful to hasten the process of unmasking the low insulin level during hypoglycaemia below the GSIR level of which insulin released is suppressed.
Collapse
Affiliation(s)
- Wann Jia Loh
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Lily Mae Dacay
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| | - Clara Si Hua Tan
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Su Fen Ang
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
| | - Fabian Yap
- Department of Paediatric Endocrinology, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Su Chi Lim
- Clinical Research Unit, Khoo Teck Puat Hospital, Singapore, Singapore
- Diabetes Centre, Admiralty Medical Centre, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University Hospital, Singapore, Singapore
| | - Joan Khoo
- Department of Endocrinology, Changi General Hospital, Singapore, Singapore
| |
Collapse
|
13
|
Amaratunga SA, Hussein Tayeb T, Rozenkova K, Kucerova P, Pruhova S, Lebl J. Congenital Hyperinsulinism Caused by Novel Homozygous KATP Channel Gene Variants May Be Linked to Unexplained Neonatal Deaths among Kurdish Consanguineous Families. Horm Res Paediatr 2021; 93:58-65. [PMID: 32203961 DOI: 10.1159/000506476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 02/01/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Neonatal hypoglycemia due to congenital hyperinsulinism (CHI) is a potentially life-threatening condition. Biallelic pathogenic variants in KATP channel subunit genes (ABCC8, KCNJ11), causing severe forms of CHI, are more prevalent in regions with a significant rate of consanguinity and may lead to unexplained neonatal deaths. We hypothesized that KATP channel gene variants are the cause of CHI in three unrelated children from consanguineous Kurdish families with histories of four unexplained neonatal deaths with convulsions. CASES (1) A girl presented on the 6th day of life with recurrent hypoglycemic convulsions (blood glucose 2.05 mmol/L, insulin 58 mIU/L, C-peptide 2,242 pmol/L). (2) A girl with severe developmental delay was diagnosed with CHI at 3 years of age (blood glucose 2.78 mmol/L, insulin 8.1 mIU/L, C-peptide 761 pmol/L) despite a history of recurrent hypoglycemia since neonatal age. (3) A girl presented at 3 weeks of age with convulsions and unconsciousness (blood glucose 2.5 mmol/L, insulin 14.6 mIU/L, C-peptide 523 pmol/L). Coding regions of the ABCC8 and KCNJ11 genes were tested by Sanger sequencing. Potential variants were evaluated using the American College of Medical Genetics standards. Three novel causative homozygous variants were found - p.Trp514Ter in the ABCC8 gene (Pt2), and p.Met1Val (Pt1) and p.Tyr26Ter (Pt3) in the KCNJ11 gene. CONCLUSION CHI caused by KATP channel variants was elucidated in three children, providing a highly probable retrospective diagnosis for their deceased siblings. Future lives can be saved by timely diagnosis of CHI when encountering a neonate with unexplained seizures or other signs of recurrent and/or persistent hypoglycemia.
Collapse
Affiliation(s)
- Shenali Anne Amaratunga
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia,
| | - Tara Hussein Tayeb
- Department of Pediatrics, Sulaymani University, College of Medicine, Sulaymani, Iraq
| | - Klara Rozenkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Petra Kucerova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Stepanka Pruhova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Jan Lebl
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| |
Collapse
|
14
|
Sims K. Congenital Hyperinsulinism. Neoreviews 2021; 22:e230-e240. [PMID: 33795398 DOI: 10.1542/neo.22-4-e230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hyperinsulinemic hypoglycemia (HH) is fairly common in neonates, particularly those born to diabetic mothers and those who are either large or small for gestational age. Immediate management of the disease focuses on achieving normoglycemia through frequent high-calorie feedings and/or intravenous glucose administration. Glucagon may be used for unstable infants in whom intravenous access cannot be obtained and enteral feedings cannot be administered. HH that persists despite these interventions should raise concern for congenital hyperinsulinism (CHI), prompting clinicians to perform a thorough evaluation. CHI consists of a group of genetic disorders in which inappropriate insulin secretion results in persistent hypoglycemia. Defects can occur in the various genes that regulate the pathway for insulin secretion in the pancreatic β-cells. Pharmacologic therapies are used for long-term management of the disease coupled with either curative or therapeutic surgical intervention. Because of the developing brain's high demand for glucose, these infants are at increased risk for hypoglycemic brain injury. This review will describe the pathogenesis of CHI, outlining the more common genetic mutations and associated syndromes. We will also discuss the clinical presentation, diagnosis, and management of CHI while providing insight into the overall prognosis.
Collapse
|
15
|
Haris B, Saraswathi S, Hussain K. Somatostatin analogues for the treatment of hyperinsulinaemic hypoglycaemia. Ther Adv Endocrinol Metab 2020; 11:2042018820965068. [PMID: 33329885 PMCID: PMC7720331 DOI: 10.1177/2042018820965068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/11/2020] [Indexed: 01/10/2023] Open
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is a biochemical finding of low blood glucose levels due to the dysregulation of insulin secretion from pancreatic β-cells. Under normal physiological conditions, glucose metabolism is coupled to β-cell insulin secretion so that blood glucose levels are maintained within the physiological range of 3.5-5.5 mmol/L. However, in HH this coupling of glucose metabolism to insulin secretion is perturbed so that insulin secretion becomes unregulated. HH typically occurs in the neonatal, infancy and childhood periods and can be due to many different causes. Adults can also present with HH but the causes in adults tend to be different. Somatostatin (SST) is a peptide hormone that is released by the delta cells (δ-cells) in the pancreas. It binds to G protein-coupled SST receptors to regulate a variety of location-specific and selective functions such as hormone inhibition, neurotransmission and cell proliferation. SST plays a potent role in the regulation of both insulin and glucagon secretion in response to changes in glucose levels by negative feedback mechanism. The half-life of SST is only 1-3 min due to quick degradation by peptidases in plasma and tissues. Thus, a direct continuous intravenous or subcutaneous infusion is required to achieve the therapeutic effect. These limitations prompted the discovery of SST analogues such as octreotide and lanreotide, which have longer half-lives and therefore can be administered as injections. SST analogues are used to treat different forms of HH in children and adults and therapeutic effect is achieved by suppressing insulin secretion from pancreatic β-cells by complex mechanisms. These treatments are associated with several side effects, especially in the newborn period, with necrotizing enterocolitis being the most serious side effect and hence SS analogues should be used with extreme caution in this age group.
Collapse
Affiliation(s)
- Basma Haris
- Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, Doha, Qatar
| | - Saras Saraswathi
- Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Professor of Paediatrics, Weill Cornell Medicine-Qatar, Division Chief – Endocrinology, Department of Paediatric Medicine, Division of Endocrinology, Sidra Medicine, OPC, C6-340 |PO Box 26999, Al Luqta Street, Education City North Campus, Doha, Qatar
| |
Collapse
|
16
|
Gϋemes M, Rahman SA, Kapoor RR, Flanagan S, Houghton JAL, Misra S, Oliver N, Dattani MT, Shah P. Hyperinsulinemic hypoglycemia in children and adolescents: Recent advances in understanding of pathophysiology and management. Rev Endocr Metab Disord 2020; 21:577-597. [PMID: 32185602 PMCID: PMC7560934 DOI: 10.1007/s11154-020-09548-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hyperinsulinemic hypoglycemia (HH) is characterized by unregulated insulin release, leading to persistently low blood glucose concentrations with lack of alternative fuels, which increases the risk of neurological damage in these patients. It is the most common cause of persistent and recurrent hypoglycemia in the neonatal period. HH may be primary, Congenital HH (CHH), when it is associated with variants in a number of genes implicated in pancreatic development and function. Alterations in fifteen genes have been recognized to date, being some of the most recently identified mutations in genes HK1, PGM1, PMM2, CACNA1D, FOXA2 and EIF2S3. Alternatively, HH can be secondary when associated with syndromes, intra-uterine growth restriction, maternal diabetes, birth asphyxia, following gastrointestinal surgery, amongst other causes. CHH can be histologically characterized into three groups: diffuse, focal or atypical. Diffuse and focal forms can be determined by scanning using fluorine-18 dihydroxyphenylalanine-positron emission tomography. Newer and improved isotopes are currently in development to provide increased diagnostic accuracy in identifying lesions and performing successful surgical resection with the ultimate aim of curing the condition. Rapid diagnostics and innovative methods of management, including a wider range of treatment options, have resulted in a reduction in co-morbidities associated with HH with improved quality of life and long-term outcomes. Potential future developments in the management of this condition as well as pathways to transition of the care of these highly vulnerable children into adulthood will also be discussed.
Collapse
Affiliation(s)
- Maria Gϋemes
- Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, WC1N 3JH, UK
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Endocrinology Service, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Sofia Asim Rahman
- Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, WC1N 3JH, UK
| | - Ritika R Kapoor
- Pediatric Diabetes and Endocrinology, King's College Hospital NHS Trust, Denmark Hill, London, UK
| | - Sarah Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Jayne A L Houghton
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Royal Devon and Exeter Foundation Trust, Exeter, UK
| | - Shivani Misra
- Department of Diabetes, Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Nick Oliver
- Department of Diabetes, Endocrinology and Metabolic Medicine, Faculty of Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Mehul Tulsidas Dattani
- Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, WC1N 3JH, UK
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Pratik Shah
- Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, Great Ormond Street, London, WC1N 3JH, UK.
- Department of Pediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK.
| |
Collapse
|
17
|
Bolmasova AV, Melikyan MA, Krylova NA, Ionov OV, Ryumina II, Bockeria EL, Pekareva NA, Degtyareva AV. [Transient hyperinsulinism in neonates]. ACTA ACUST UNITED AC 2020; 66:61-67. [PMID: 33351360 DOI: 10.14341/probl12572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/06/2022]
Abstract
Congenital hyperinsulinusm is rare disease characterized high secretion of insulin by pancreatic beta cells leading to the development of hypoglycemia. Persistent and transient forms of hyperinsulinism are distinguished. Transient hyperinsulinism are the most common cause of severe hypoglycemia in newborns. The etiology of this disease is not known. There are risk factors for the development of transient hyperinsulinism: asphyxia at birth, prematurity, maternal diabetes, low or large weight by gestation. Hypoglycemia with hyperinsulinism is severe. Therefore, early diagnosis and therapy especially during the neonatal period, are necessary.The article describes 3 clinical cases of transient hyperinsulinism in children with different gestational age and concomitant pathology. All children recevied insulinostatic therapy with diazoxide with a positive effect: euglycemia without glucose requirement . In all children, therapy was completed subsequently. At the time of publication of the article, the physical and psychomotor development of children is normal.
Collapse
Affiliation(s)
- Anna V Bolmasova
- Kulakov Federal Rеseаrch Center for Obstetrics, Gynecology and Perinatology; Endocrinology research Centre
| | - Maria A Melikyan
- Kulakov Federal Rеseаrch Center for Obstetrics, Gynecology and Perinatology
| | - Natalya A Krylova
- Kulakov Federal Rеseаrch Center for Obstetrics, Gynecology and Perinatology
| | - Oleg V Ionov
- Kulakov Federal Rеseаrch Center for Obstetrics, Gynecology and Perinatology
| | - Irina I Ryumina
- Kulakov Federal Rеseаrch Center for Obstetrics, Gynecology and Perinatology
| | | | - Natalya A Pekareva
- Kulakov Federal Rеseаrch Center for Obstetrics, Gynecology and Perinatology
| | - Anna V Degtyareva
- Kulakov Federal Rеseаrch Center for Obstetrics, Gynecology and Perinatology
| |
Collapse
|
18
|
Papulino C, Chianese U, Nicoletti MM, Benedetti R, Altucci L. Preclinical and Clinical Epigenetic-Based Reconsideration of Beckwith-Wiedemann Syndrome. Front Genet 2020; 11:563718. [PMID: 33101381 PMCID: PMC7522569 DOI: 10.3389/fgene.2020.563718] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/26/2020] [Indexed: 12/26/2022] Open
Abstract
Epigenetics has achieved a profound impact in the biomedical field, providing new experimental opportunities and innovative therapeutic strategies to face a plethora of diseases. In the rare diseases scenario, Beckwith-Wiedemann syndrome (BWS) is a pediatric pathological condition characterized by a complex molecular basis, showing alterations in the expression of different growth-regulating genes. The molecular origin of BWS is associated with impairments in the genomic imprinting of two domains at the 11p15.5 chromosomal region. The first domain contains three different regions: insulin growth like factor gene (IGF2), H19, and abnormally methylated DMR1 region. The second domain consists of cell proliferation and regulating-genes such as CDKN1C gene encoding for cyclin kinase inhibitor its role is to block cell proliferation. Although most cases are sporadic, about 5-10% of BWS patients have inheritance characteristics. In the 11p15.5 region, some of the patients have maternal chromosomal rearrangements while others have Uniparental Paternal Disomy UPD(11)pat. Defects in DNA methylation cause alteration of genes and the genomic structure equilibrium leading uncontrolled cell proliferation, which is a typical tumorigenesis event. Indeed, in BWS patients an increased childhood tumor predisposition is observed. Here, we summarize the latest knowledge on BWS and focus on the impact of epigenetic alterations to an increased cancer risk development and to metabolic disorders. Moreover, we highlight the correlation between assisted reproductive technologies and this rare disease. We also discuss intriguing aspects of BWS in twinning. Epigenetic therapies in clinical trials have already demonstrated effectiveness in oncological and non-oncological diseases. In this review, we propose a potential "epigenetic-based" approaches may unveil new therapeutic options for BWS patients. Although the complexity of the syndrome is high, patients can be able to lead a normal life but tumor predispositions might impair life expectancy. In this sense epigenetic therapies should have a supporting role in order to guarantee a good prognosis.
Collapse
Affiliation(s)
- Chiara Papulino
- Department of Precision Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Ugo Chianese
- Department of Precision Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Maddalena Nicoletti
- Department of Precision Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Rosaria Benedetti
- Department of Precision Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Lucia Altucci
- Department of Precision Medicine, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
19
|
Gomes-Porras M, Cárdenas-Salas J, Álvarez-Escolá C. Somatostatin Analogs in Clinical Practice: a Review. Int J Mol Sci 2020; 21:ijms21051682. [PMID: 32121432 PMCID: PMC7084228 DOI: 10.3390/ijms21051682] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/22/2020] [Accepted: 02/25/2020] [Indexed: 12/14/2022] Open
Abstract
Somatostatin analogs are an invaluable therapeutic option in the diagnosis and treatment of somatotropinomas, thyrotropinomas, and functioning and non-functioning gastroenteropancreatic neuroendocrine tumors. They should also be considered an effective and safe therapeutic alternative to corticotropinomas, gonadotropinomas, and prolactinomas resistant to dopamine agonists. Somatostatin analogs have also shown to be useful in the treatment of other endocrine diseases (congenital hyperinsulinism, Graves’ orbitopathy, diabetic retinopathy, diabetic macular edema), non-endocrine tumors (breast, colon, prostate, lung, and hepatocellular), and digestive diseases (chronic refractory diarrhea, hepatorenal polycystosis, gastrointestinal hemorrhage, dumping syndrome, and intestinal fistula).
Collapse
Affiliation(s)
- Mariana Gomes-Porras
- Department of Endocrinology, “La Paz” University Hospital. Paseo de la Castellana, 261, 28046 Madrid, Spain;
| | - Jersy Cárdenas-Salas
- Department of Endocrinology, “Fundación Jiménez-Diaz” University Hospital. Av. de los Reyes Católicos, 2, 28040 Madrid, Spain;
| | - Cristina Álvarez-Escolá
- Department of Endocrinology, “La Paz” University Hospital. Paseo de la Castellana, 261, 28046 Madrid, Spain;
- Correspondence: ; Tel.: +34-917-277-209
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Paauw ND, Stegeman R, de Vroede MAMJ, Termote JUM, Freund MW, Breur JMPJ. Neonatal cardiac hypertrophy: the role of hyperinsulinism-a review of literature. Eur J Pediatr 2020; 179:39-50. [PMID: 31840185 PMCID: PMC6942572 DOI: 10.1007/s00431-019-03521-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/30/2019] [Accepted: 10/31/2019] [Indexed: 12/13/2022]
Abstract
Hypertrophic cardiomyopathy (HCM) in neonates is a rare and heterogeneous disorder which is characterized by hypertrophy of heart with histological and functional disruption of the myocardial structure/composition. The prognosis of HCM depends on the underlying diagnosis. In this review, we emphasize the importance to consider hyperinsulinism in the differential diagnosis of HCM, as hyperinsulinism is widely associated with cardiac hypertrophy (CH) which cannot be distinguished from HCM on echocardiographic examination. We supply an overview of the incidence and treatment strategies of neonatal CH in a broad spectrum of hyperinsulinemic diseases. Reviewing the literature, we found that CH is reported in 13 to 44% of infants of diabetic mothers, in approximately 40% of infants with congenital hyperinsulinism, in 61% of infants with leprechaunism and in 48 to 61% of the patients with congenital generalized lipodystrophy. The correct diagnosis is of importance since there is a large variation in prognoses and there are various strategies to treat CH in hyperinsulinemic diseases.Conclusion: The relationship between CH and hyperinsulism has implications for clinical practice as it might help to establish the correct diagnosis in neonates with cardiac hypertrophy which has both prognostic and therapeutic consequences. In addition, CH should be recognized as a potential comorbidity which might necessitate treatment in all neonates with known hyperinsulinism.What is Known:• Hyperinsulinism is currently not acknowledged as a cause of hypertrophic cardiomyopathy (HCM) in textbooks and recent Pediatric Cardiomyopathy Registry publications.What is New:• This article presents an overview of the literature of hyperinsulinism in neonates and infants showing that hyperinsulinism is associated with cardiac hypertrophy (CH) in a broad range of hyperinsulinemic diseases.• As CH cannot be distinguished from HCM on echocardiographic examination, we emphasize the importance to consider hyperinsulinism in the differential diagnosis of HCM/CH as establishing the correct diagnosis has both prognostic and therapeutic consequences.
Collapse
Affiliation(s)
- Nina D. Paauw
- grid.7692.a0000000090126352Department of Obstetrics, Wilhelmina Children’s Hospital Birth Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Raymond Stegeman
- grid.7692.a0000000090126352Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands ,grid.7692.a0000000090126352Department of Neonatology, Wilhelmina Children’s Hospital Birth Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Monique A. M. J. de Vroede
- grid.7692.a0000000090126352Department of Pediatric Endocrinology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jacqueline U. M. Termote
- grid.7692.a0000000090126352Department of Neonatology, Wilhelmina Children’s Hospital Birth Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Matthias W. Freund
- grid.5560.60000 0001 1009 3608Department of Pediatric Cardiology, Klinikum Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Johannes M. P. J. Breur
- grid.7692.a0000000090126352Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center Utrecht, PO Box 85090, 3508 AB Utrecht, The Netherlands
| |
Collapse
|
22
|
Wackernagel D, Gustafsson A, Edstedt Bonamy A, Reims A, Ahlsson F, Elfving M, Domellöf M, Hansen Pupp I. Swedish national guideline for prevention and treatment of neonatal hypoglycaemia in newborn infants with gestational age ≥35 weeks. Acta Paediatr 2020; 109:31-44. [PMID: 31350926 DOI: 10.1111/apa.14955] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 05/18/2019] [Accepted: 07/25/2019] [Indexed: 01/22/2023]
Abstract
AIM Postnatal hypoglycaemia in newborn infants remains an important clinical problem where prolonged periods of hypoglycaemia are associated with poor neurodevelopmental outcome. The aim was to develop an evidence-based national guideline with the purpose to optimise prevention, diagnosis and treatment of hypoglycaemia in newborn infants with a gestational age ≥35 + 0 weeks. METHODS A PubMed search-based literature review was used to find actual and applicable evidence for all incorporated recommendations. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used for grading the evidence of the recommendations. RESULTS Recommendations for the prevention of neonatal hypoglycaemia were extended and updated, focusing on promotion of breastfeeding as one prevention strategy. Oral dextrose gel as a novel supplemental therapy was incorporated in the treatment protocol. A new threshold-based screening and treatment protocol presented as a flow chart was developed. CONCLUSION An updated and evidence-based national guideline for screening and treatment of neonatal hypoglycaemia will support standardised regimes, which may prevent hypoglycaemia and the risk for hypoglycaemia-related long-term sequelae.
Collapse
Affiliation(s)
- Dirk Wackernagel
- Karolinska University Hospital and Karolinska Institutet Stockholm Sweden
| | - Anna Gustafsson
- Karolinska University Hospital and Karolinska Institutet Stockholm Sweden
| | | | - Annika Reims
- Queen Silvia Children's Hospital Gothenburg Sweden
| | - Fredrik Ahlsson
- Uppsala University Children's hospital and Department of Women's and Children's Health Uppsala University Uppsala Sweden
| | - Maria Elfving
- Department of Clinical Sciences Lund, Pediatrics Skane University Hospital Lund University Lund Sweden
| | | | | |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Xu A, Cheng J, Sheng H, Wen Z, Lin Y, Zhou Z, Zeng C, Shao Y, Li C, Liu L, Li X. Clinical Management and Gene Mutation Analysis of Children with Congenital Hyperinsulinism in South China. J Clin Res Pediatr Endocrinol 2019; 11:400-409. [PMID: 31208162 PMCID: PMC6878346 DOI: 10.4274/jcrpe.galenos.2019.2019.0046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To explore the clinical presentation and molecular genetic characteristics of a cohort of congenital hyperinsulinism (CHI) patients from southern China and also to explore the most appropriate therapeutic approaches. METHODS We retrospectively reviewed a cohort of 65 children with CHI. Mutational analysis was performed for KCNJ11 and ABCC8 genes. The GLUD1 gene was sequenced in patients with hyperammonaemia. GCK gene sequencing was performed in those patients with no mutation identified in the ABCC8, KCNJ11 or GLUD1 genes. RESULTS ABCC8 mutations were identified in 16 (25%) of the cohort, GLUD1 mutations were identified in five children, and no KCNJ11 or GCK mutations were identified. Moreover, some unique features of ABCC8 gene mutations in southern Chinese CHI patients were found in this study. The most common mutation was a deletion/insertion mutation p.Thr1042GlnfsX75 was found in five unrelated patients, which possibly represents a relatively common mutation in southern China. Five novel ABCC8 mutations were detected. The mutations were p.Phe5SerfsX72, p.Gln273ArgfsX85, p.Leu724del, p.Asp1447Gly and IVS 25-1G>T. Five compound heterozygous mutations of ABCC8 gene were identified in this study, and three of these patients were diazoxide-responsive. Forty patients were diazoxide-responsive, 13 patients were diazoxide-unresponsive and 12 patients received dietary treatment only. A pancreatectomy was performed in 10 patients who were unresponsive to medical treatment. CONCLUSION To the best of our knowledge, this is the first study of CHI in south China. Mutations in ABCC8 are the most common causes of CHI in this cohort. Diazoxide and dietary treatment were effective in most patients. Multicentre studies are necessary to obtain the long-term follow-up characteristics of such patients at a national level.
Collapse
Affiliation(s)
- Aijing Xu
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China,Contributed equally to this work
| | - Jing Cheng
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China,Contributed equally to this work
| | - Huiying Sheng
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Zhe Wen
- Guangzhou Women and Children’s Medical Center, Clinic of Pediatric Surgery, Guangzhou, China
| | - Yunting Lin
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Zhihong Zhou
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Chunhua Zeng
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Yongxian Shao
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Cuiling Li
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Li Liu
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China
| | - Xiuzhen Li
- Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China,* Address for Correspondence: Guangzhou Women and Children’s Medical Center, Clinic of Genetics and Endocrinology, Guangzhou, China Phone: +86020-38076127 E-mail:
| |
Collapse
|
25
|
Kostopoulou E, Shah P. Hyperinsulinaemic hypoglycaemia-an overview of a complex clinical condition. Eur J Pediatr 2019; 178:1151-1160. [PMID: 31243576 DOI: 10.1007/s00431-019-03414-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 12/18/2022]
Abstract
Hyperinsulinaemic hypoglycaemia (HH) is a major cause of hypoglycaemia in the neonatal period, infancy and childhood. It is caused by unsuppressed insulin secretion in the setting of hypoglycaemia and carries a high risk of significant neurological sequelae, such as cognitive impairment. Genetic mutations have been implicated in the pathogenesis of the condition. Other causes include intra-uterine growth retardation, perinatal asphyxia, maternal diabetes mellitus and syndromes, such as Beckwith-Wiedemann. Based on the aetiology, the clinical presentation can range from absence of symptoms to the typical adrenergic symptoms and coma and even death. The diagnosis is based on biochemical findings and the gold-standard imaging technique is 18F-DOPA PET/CT scanning. Treatment options involve medications, such as diazoxide, nifedipine, glucagon and octreotide, as well as surgery. Novel treatment, such as long-acting octreotide, lanreotide and sirolimus, may be used as an alternative to pancreatectomy. Potential future medical treatments include exendin, a GLP-1 receptor antagonist, and glucagon infusion via a pump.Conclusion: Advances in the fields of genetic testing, imaging techniques and medical treatment are beginning to provide novel insights into earlier detection, less invasive treatment approaches and fewer complications associated with the complex entity of hyperinsulinaemic hypoglycaemia. What is Known: • HH is caused by dysregulated insulin release from the β cell due to genetic mutations and carries a risk for complications, such as neurocognitive impairment. 18F-DOPA PET/CT scanning is presented as the gold-standard imaging technique currently in children with hyperinsulinaemic hypoglycaemia. • Clinical presentation is heterogeneous and treatment options include medical therapy and pancreatectomy. What is New: • 18F-DOPA PET/CT is indicated in suspected focal CHI due to paternal transmitted mutations in ABCC8 or KCNJ11. • Novel treatment options have been introduced, such as long-acting octreotide, lanreotide, sirolimus and selective nonpeptide somatostatin receptor subtype 5 (SSTR5) agonists. Future medical treatments include exendin, a GLP-1 antagonist, and glucagon infusion via a pump. However, all these options are off-label at present.
Collapse
Affiliation(s)
- Eirini Kostopoulou
- Research Laboratory of the Division of Paediatric Endocrinology and Diabetes, Department of Paediatrics, School of Medicine, University of Patras, 26500, Patras, Greece.
| | - Pratik Shah
- Endocrinology Department, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine Programme, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| |
Collapse
|
26
|
Arya VB, Kalitsi J, Hickey A, Flanagan SE, Kapoor RR. Exceptional diazoxide sensitivity in hyperinsulinaemic hypoglycaemia due to a novel HNF4A mutation. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM190013. [PMID: 31096182 PMCID: PMC6528403 DOI: 10.1530/edm-19-0013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/25/2019] [Indexed: 12/14/2022] Open
Abstract
Diazoxide is the first-line treatment for patients with hyperinsulinaemic hypoglycaemia (HH). Approximately 50% of patients with HH are diazoxide resistant. However, marked diazoxide sensitivity resulting in severe hyperglycaemia is extremely uncommon and not reported previously in the context of HH due to HNF4A mutation. We report a novel observation of exceptional diazoxide sensitivity in a patient with HH due to HNF4A mutation. A female infant presented with severe persistent neonatal hypoglycaemia and was diagnosed with HH. Standard doses of diazoxide (5 mg/kg/day) resulted in marked hyperglycaemia (maximum blood glucose 21.6 mmol/L) necessitating discontinuation of diazoxide. Lower dose of diazoxide (1.5 mg/kg/day) successfully controlled HH in the proband, which was subsequently confirmed to be due to a novel HNF4A mutation. At 3 years of age, the patient maintains age appropriate fasting tolerance on low dose diazoxide (1.8 mg/kg/day) and has normal development. Diagnosis in proband's mother and maternal aunt, both of whom carried HNF4A mutation and had been diagnosed with presumed type 1 and type 2 diabetes mellitus, respectively, was revised to maturity-onset diabetes of young (MODY). Proband's 5-year-old maternal cousin, also carrier of HNF4A mutation, had transient neonatal hypoglycaemia. To conclude, patients with HH due to HNF4A mutation may require lower diazoxide than other group of patients with HH. Educating the families about the risk of marked hyperglycaemia with diazoxide is essential. The clinical phenotype of HNF4A mutation can be extremely variable. Learning points: Awareness of risk of severe hyperglycaemia with diazoxide is important and patients/families should be accordingly educated. Some patients with HH due to HNF4A mutations may require lower than standard doses of diazoxide. The clinical phenotype of HNF4A mutation can be extremely variable.
Collapse
Affiliation(s)
- Ved Bhushan Arya
- Department of Paediatric Endocrinology, Variety Club Children’s Hospital, King’s College Hospital NHS Foundation Trust, London, UK
| | - Jennifer Kalitsi
- Department of Paediatric Endocrinology, Variety Club Children’s Hospital, King’s College Hospital NHS Foundation Trust, London, UK
| | - Ann Hickey
- Department of Neonatology, King’s College Hospital NHS Foundation Trust, London, UK
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter, Exeter, UK
| | - Ritika R Kapoor
- Department of Paediatric Endocrinology, Variety Club Children’s Hospital, King’s College Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
27
|
Muukkonen L, Männistö J, Jääskeläinen J, Hannonen R, Huopio H. The effect of hypoglycaemia on neurocognitive outcome in children and adolescents with transient or persistent congenital hyperinsulinism. Dev Med Child Neurol 2019; 61:451-457. [PMID: 30246438 DOI: 10.1111/dmcn.14039] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2018] [Indexed: 02/06/2023]
Abstract
AIM To examine the hypoglycaemic effect on neurodevelopmental outcome in patients with transient and persistent congenital hyperinsulinism (CHI) born in the 21st century. METHOD A cohort of 117 patients (66 males, 51 females) with CHI aged 5 to 16 years (mean age 8y 11mo, SD 2y 7mo) were selected from a Finnish nationwide registry to examine all the patients with similar methods. Neurodevelopment was first evaluated retrospectively. The 83 patients with no risk factors for neurological impairment other than hypoglycaemia were recruited and 44 participated (24 males, 20 females; mean age 9y 7mo, SD 3y 1mo) in neuropsychological assessment with the Wechsler Intelligence Scale for Children, Fourth Edition and the Finnish version of the Developmental Neuropsychological Assessment, Second Edition domains of attention, language, memory, sensorimotor, and visual functioning. RESULTS In retrospective analysis, transient and persistent CHI groups had similar prevalences of mild (22% and 18% respectively) or severe (5% and 7% respectively) neurodevelopmental difficulties. In clinical assessment, the neurocognitive profile was within the average range in both groups, but children with persistent CHI showed significant but restricted deficits in attention, memory, visual, and sensorimotor functions compared with the general population. The transient CHI group did not differ from the standardization samples. INTERPRETATION Besides the more apparent broader neurological deficits, children with persistent CHI have an increased risk for milder specific neurocognitive problems, which should be considered in the follow-up. WHAT THIS PAPER ADDS Children with persistent congenital hyperinsulinism showed deficits in attention, memory, visual, and sensorimotor functions. The deficits were potentially of hypoglycaemic origin. Children with transient hyperinsulinism did not differ from the general population.
Collapse
Affiliation(s)
- Liisa Muukkonen
- Department of Child Neurology, Siun sote North Karelia Central Hospital, Joensuu, Finland.,Coronaria Tietotaito, Joensuu, Finland
| | - Jonna Männistö
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland.,Department of Paediatrics, University of Eastern Finland, Kuopio, Finland
| | - Jarmo Jääskeläinen
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland.,Department of Paediatrics, University of Eastern Finland, Kuopio, Finland
| | - Riitta Hannonen
- Department of Psychology, Carea - Kymenlaakso Social and Health Services, Kotka, Finland.,Department of Psychology, University of Jyväskylä, Jyväskylä, Finland
| | - Hanna Huopio
- Department of Paediatrics, Kuopio University Hospital, Kuopio, Finland
| |
Collapse
|
28
|
Kiff S, Babb C, Guemes M, Dastamani A, Gilbert C, Flanagan SE, Ellard S, Barton J, Dattani M, Shah P. Partial diazoxide responsiveness in a neonate with hyperinsulinism due to homozygous ABCC8 mutation. Endocrinol Diabetes Metab Case Rep 2019; 2019:EDM180120. [PMID: 30753133 PMCID: PMC6373619 DOI: 10.1530/edm-18-0120] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 01/08/2019] [Indexed: 01/21/2023] Open
Abstract
We report a case of partial diazoxide responsiveness in a child with severe congenital hyperinsulinaemic hypoglycaemia (CHI) due to a homozygous ABCC8 mutation. A term baby, with birth weight 3.8 kg, born to consanguineous parents presented on day 1 of life with hypoglycaemia. Hypoglycaemia screen confirmed CHI. Diazoxide was commenced on day 7 due to ongoing elevated glucose requirements (15 mg/kg/min), but despite escalation to a maximum dose (15 mg/kg/day), intravenous (i.v.) glucose requirement remained high (13 mg/kg/min). Genetic testing demonstrated a homozygous ABCC8 splicing mutation (c.2041-1G>C), consistent with a diffuse form of CHI. Diazoxide treatment was therefore stopped and subcutaneous (s.c.) octreotide infusion commenced. Despite this, s.c. glucagon and i.v. glucose were required to prevent hypoglycaemia. A trial of sirolimus and near-total pancreatectomy were considered, however due to the significant morbidity potentially associated with these, a further trial of diazoxide was commenced at 1.5 months of age. At a dose of 10 mg/kg/day of diazoxide and 40 µg/kg/day of octreotide, both i.v. glucose and s.c. glucagon were stopped as normoglycaemia was achieved. CHI due to homozygous ABCC8 mutation poses management difficulties if the somatostatin analogue octreotide is insufficient to prevent hypoglycaemia. Diazoxide unresponsiveness is often thought to be a hallmark of recessively inherited ABCC8 mutations. This patient was initially thought to be non-responsive, but this case highlights that a further trial of diazoxide is warranted, where other available treatments are associated with significant risk of morbidity. Learning points: Homozygous ABCC8 mutations are commonly thought to cause diazoxide non-responsive hyperinsulinaemic hypoglycaemia. This case highlights that partial diazoxide responsiveness in homozygous ABCC8 mutations may be present. Trial of diazoxide treatment in combination with octreotide is warranted prior to considering alternative treatments, such as sirolimus or near-total pancreatectomy, which are associated with more significant side effects.
Collapse
Affiliation(s)
- Sarah Kiff
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Department of Endocrinology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Carolyn Babb
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Maria Guemes
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Programme, Great Institute of Child Health, University College London, London, UK
| | - Antonia Dastamani
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Clare Gilbert
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Sarah E Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - John Barton
- Department of Paediatric Endocrinology, Bristol Royal Hospital for Children, Bristol, UK
| | - M Dattani
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Programme, Great Institute of Child Health, University College London, London, UK
| | - Pratik Shah
- Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK
- Genetics and Genomic Medicine Programme, Great Institute of Child Health, University College London, London, UK
| |
Collapse
|
29
|
Galcheva S, Demirbilek H, Al-Khawaga S, Hussain K. The Genetic and Molecular Mechanisms of Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2019; 10:111. [PMID: 30873120 PMCID: PMC6401612 DOI: 10.3389/fendo.2019.00111] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/06/2019] [Indexed: 12/13/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is a heterogenous and complex disorder in which the unregulated insulin secretion from pancreatic beta-cells leads to hyperinsulinaemic hypoglycaemia. The severity of hypoglycaemia varies depending on the underlying molecular mechanism and genetic defects. The genetic and molecular causes of CHI include defects in pivotal pathways regulating the secretion of insulin from the beta-cell. Broadly these genetic defects leading to unregulated insulin secretion can be grouped into four main categories. The first group consists of defects in the pancreatic KATP channel genes (ABCC8 and KCNJ11). The second and third categories of conditions are enzymatic defects (such as GDH, GCK, HADH) and defects in transcription factors (for example HNF1α, HNF4α) leading to changes in nutrient flux into metabolic pathways which converge on insulin secretion. Lastly, a large number of genetic syndromes are now linked to hyperinsulinaemic hypoglycaemia. As the molecular and genetic basis of CHI has expanded over the last few years, this review aims to provide an up-to-date knowledge on the genetic causes of CHI.
Collapse
Affiliation(s)
- Sonya Galcheva
- Department of Paediatrics, University Hospital St. Marina, Varna Medical University, Varna, Bulgaria
| | - Hüseyin Demirbilek
- Department of Paediatric Endocrinology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Sara Al-Khawaga
- Division of Endocrinology, Department of Paediatric Medicine, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Division of Endocrinology, Department of Paediatric Medicine, Sidra Medicine, Doha, Qatar
- *Correspondence: Khalid Hussain
| |
Collapse
|
30
|
van der Steen I, van Albada ME, Mohnike K, Christesen HT, Empting S, Salomon-Estebanez M, Greve Rasmussen A, Verrijn Stuart A, van der Linde AAA, Banerjee I, Boot AM. A Multicenter Experience with Long-Acting Somatostatin Analogues in Patients with Congenital Hyperinsulinism. Horm Res Paediatr 2018; 89:82-89. [PMID: 29241206 DOI: 10.1159/000485184] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 11/10/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Congenital hyperinsulinism (CHI) is a rare disease characterized by recurrent severe hypoglycemia. In the diffuse form of CHI, pharmacotherapy is the preferred choice of treatment. Long-acting somatostatin analogues have been used in children as off-label medication. However, the efficacy, outcomes, and adverse effect profiles of long-acting somatostatin analogues have not been described in multicentered studies. The aim of this retrospective study is to summarize the experience with long-acting somatostatin analogues in a large group of children with CHI. METHODS Data were obtained retrospectively from 27 patients with CHI who received long-acting somatostatin analogues in 6 different centers in Europe. These included information on glycemic stability, auxology, and adverse effect profile in clinical follow-up assessments. RESULTS Blood glucose control improved in most patients (89%). No life-threatening side effects occurred. Thirteen patients (48%) experienced side effects; in 3 patients (11%), the side effects were the main reason for discontinuation of the treatment. The most frequent side effect was elevated liver enzymes (n = 10, 37%). CONCLUSION Long-acting somatostatin analogues are effective in glycemic control of patients with CHI. However, in 37% of all patients increased liver enzymes were observed. It is important to monitor liver function in all patients receiving long-acting somatostatin analogue therapy.
Collapse
Affiliation(s)
- Ivo van der Steen
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mirjam E van Albada
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Klaus Mohnike
- Department of Pediatrics, Otto-von-Guericke University, Magdeburg, Germany
| | - Henrik Thybo Christesen
- Hans Christian Andersen Children's Hospital and Odense Pancreas Center OPAC, Odense University Hospital, Odense, Denmark
| | - Susann Empting
- Department of Pediatrics, Otto-von-Guericke University, Magdeburg, Germany
| | - Maria Salomon-Estebanez
- Department of Pediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | | | - Annemarie Verrijn Stuart
- Department of Pediatric Endocrinology, University Medical Center Utrecht - Wilhelmina Children's Hospital, Utrecht, the Netherlands
| | - Annelieke A A van der Linde
- Department of Pediatric Endocrinology, Radboud University Medical Center - Amalia Children's Hospital, Nijmegen, the Netherlands
| | - Indraneel Banerjee
- Department of Pediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Annemieke M Boot
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| |
Collapse
|
31
|
Alsaffar H, Turner L, Yung Z, Didi M, Senniappan S. Continuous Flash Glucose Monitoring in children with Congenital Hyperinsulinism; first report on accuracy and patient experience. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2018; 2018:3. [PMID: 29599801 PMCID: PMC5870486 DOI: 10.1186/s13633-018-0057-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/09/2018] [Indexed: 11/10/2022]
Abstract
Background The factory calibrated FreeStyle Libre (FSL) flash glucose monitoring system has been recently introduced for use in patients with diabetes mellitus. There are no reports available regarding its use in patients with congenital hyperinsulinism (CHI). We have assessed the accuracy of FSL compared to the finger prick capillary blood glucose (CBG) over 2 weeks period in patients with CHI and evaluated the parents’ experience of using FSL. Methods Four hundred sixty-seven episodes of CBG along with corresponding swipe FSL readings were available from 11 children with CHI (0.5–5 years). A detailed questionnaire was completed by the parents. Results The mean variation between the two methods was 0.29 mmol/l (SD ±1.07), higher readings by FSL compared to CBG. The FSL sensors stayed in-situ for an average period of 11.5 days. There was a positive correlation between the two methods (r = 0.7). The FSL tended to overestimate compared to CBG (bias = 0.29 mmol/l; 95% CI: 0.19 to 0.38). Only 70% of values were within the reference standard (±0.83 mmol/l) at glucose concentrations less than 5.6 mmol/l. The overall Mean Absolute Relative Difference (MARD) was 17.9%. Forty two episodes of hypoglycaemia (CBG < 3.5 mmol/l) were noted but FSL identified only 52% of these episodes. The Bland Altman analysis showed the 95% limits of agreement between the two methods ranging from − 1.8 (95% CI: -1.97 to − 1.64) to 2.37 (95% CI: 2.21 to 2.54). Majority of the parents found the glucose trend on FSL to be useful to detect and prevent hypoglycaemic episodes. All parents felt that FSL is a very easy and convenient method to measure the glucose especially during sleep. A significant proportion of parents felt that FSL readings were not accurate and 56% of parents expressed interest to continue using FSL after the trial period. Conclusion Noticeable variability between the two methods of measuring the glucose was noted. Despite the ease of using the FSL system, concerns related to accuracy, especially at low glucose values do remain although parents find the glucose trend to be very useful. Further larger trials are needed in CHI patients before FSL is recommended as a routine alternative method for measuring glucose levels.
Collapse
Affiliation(s)
- Hussain Alsaffar
- 1Department of Paediatrics, Leighton Hospital, Crewe, CW1 4QJ UK
| | - Lucy Turner
- 2Department of Paediatric Endocrinology, Alder Hey Children's Hospital, L14 5AB, Liverpool, UK
| | - Zoe Yung
- 2Department of Paediatric Endocrinology, Alder Hey Children's Hospital, L14 5AB, Liverpool, UK
| | - Mohammed Didi
- 2Department of Paediatric Endocrinology, Alder Hey Children's Hospital, L14 5AB, Liverpool, UK
| | - Senthil Senniappan
- 2Department of Paediatric Endocrinology, Alder Hey Children's Hospital, L14 5AB, Liverpool, UK
| |
Collapse
|
32
|
Laguna Sanz AJ, Mulla CM, Fowler KM, Cloutier E, Goldfine AB, Newswanger B, Cummins M, Deshpande S, Prestrelski SJ, Strange P, Zisser H, Doyle FJ, Dassau E, Patti ME. Design and Clinical Evaluation of a Novel Low-Glucose Prediction Algorithm with Mini-Dose Stable Glucagon Delivery in Post-Bariatric Hypoglycemia. Diabetes Technol Ther 2018; 20:127-139. [PMID: 29355439 PMCID: PMC5771550 DOI: 10.1089/dia.2017.0298] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) is a complication of bariatric surgery with limited therapeutic options. We developed an event-based system to predict and detect hypoglycemia based on continuous glucose monitor (CGM) data and recommend delivery of minidose liquid glucagon. METHODS We performed an iterative development clinical study employing a novel glucagon delivery system: a Dexcom CGM connected to a Windows tablet running a hypoglycemia prediction algorithm and an Omnipod pump filled with an investigational stable liquid glucagon formulation. Meal tolerance testing was performed in seven participants with PBH and history of neuroglycopenia. Glucagon was administered when hypoglycemia was predicted. Primary outcome measures included the safety and feasibility of this system to predict and prevent severe hypoglycemia. Secondary outcomes included hypoglycemia prediction by the prediction algorithm, minimization of time below hypoglycemia threshold using glucagon, and prevention of rebound hyperglycemia. RESULTS The hypoglycemia prediction algorithm alerted for impending hypoglycemia in the postmeal state, prompting delivery of glucagon (150 μg). After observations of initial incomplete efficacy to prevent hypoglycemia in the first two participants, system modifications were implemented: addition of PBH-specific detection algorithm, increased glucagon dose (300 μg), and a second glucagon dose if needed. These modifications, together with rescue carbohydrates provided to some participants, contributed to progressive improvements in glucose time above the hypoglycemia threshold (75 mg/dL). CONCLUSIONS Preliminary results indicate that our event-based automatic monitoring algorithm successfully predicted likely hypoglycemia. Minidose glucagon therapy was well tolerated, without prolonged or severe hypoglycemia, and without rebound hyperglycemia.
Collapse
Affiliation(s)
- Alejandro J. Laguna Sanz
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | | | | | - Emilie Cloutier
- Research Division, Joslin Diabetes Center, Boston, Massachusetts
| | | | - Brett Newswanger
- Research and Development Xeris Pharmaceuticals, Inc., Austin, Texas
| | - Martin Cummins
- Research and Development Xeris Pharmaceuticals, Inc., Austin, Texas
| | - Sunil Deshpande
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | | | - Poul Strange
- Research and Development Xeris Pharmaceuticals, Inc., Austin, Texas
| | - Howard Zisser
- Department of Chemical Engineering, University of California, Santa Barbara, Santa Barbara, California
| | - Francis J. Doyle
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
- Research Division, Joslin Diabetes Center, Boston, Massachusetts
| | | |
Collapse
|
33
|
Abstract
Pancreatic β-cells are finely tuned to secrete insulin so that plasma glucose levels are maintained within a narrow physiological range (3.5-5.5 mmol/L). Hyperinsulinaemic hypoglycaemia (HH) is the inappropriate secretion of insulin in the presence of low plasma glucose levels and leads to severe and persistent hypoglycaemia in neonates and children. Mutations in 12 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1 and PMM2) that are involved in the regulation of insulin secretion from pancreatic β-cells have been described to be responsible for the underlying molecular mechanisms leading to congenital HH. In HH due to the inhibitory effect of insulin on lipolysis and ketogenesis there is suppressed ketone body formation in the presence of hypoglycaemia thus leading to increased risk of hypoglycaemic brain injury. Therefore, a prompt diagnosis and immediate management of HH is essential to avoid hypoglycaemic brain injury and long-term neurological complications in children. Advances in molecular genetics, imaging techniques (18F-DOPA positron emission tomography/computed tomography scanning), medical therapy and surgical advances (laparoscopic and open pancreatectomy) have changed the management and improved the outcome of patients with HH. This review article provides an overview to the background, clinical presentation, diagnosis, molecular genetics and therapy in children with different forms of HH.
Collapse
Affiliation(s)
- Hüseyin Demirbilek
- Hacettepe University Faculty of Medicine, Department of Paediatric Endocrinology, Ankara, Turkey
| | - Khalid Hussain
- Sidra Medical and Research Center, Clinic of Paediatric Medicine, Doha, Qatar
,* Address for Correspondence: Sidra Medical and Research Center, Clinic of Paediatric Medicine, Doha, Qatar Phone: +974-30322007 E-mail:
| |
Collapse
|
34
|
Shah P, Rahman SA, Demirbilek H, Güemes M, Hussain K. Hyperinsulinaemic hypoglycaemia in children and adults. Lancet Diabetes Endocrinol 2017; 5:729-742. [PMID: 27915035 DOI: 10.1016/s2213-8587(16)30323-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 09/16/2016] [Accepted: 09/28/2016] [Indexed: 02/08/2023]
Abstract
Pancreatic β cells are functionally programmed to release insulin in response to changes in plasma glucose concentration. Insulin secretion is precisely regulated so that, under normal physiological conditions, fasting plasma glucose concentrations are kept within a narrow range of 3·5-5·5 mmol/L. In hyperinsulinaemic hypoglycaemia, insulin secretion becomes dysregulated (ie, uncoupled from glucose metabolism) so that insulin secretion persists in the presence of low plasma glucose concentrations. Hyperinsulinaemic hypoglycaemia is the most common cause of severe and persistent hypoglycaemia in neonates and children. At a molecular level, mutations in nine different genes can lead to the dysregulation of insulin secretion and cause this disorder. In adults, hyperinsulinaemic hypoglycaemia accounts for 0·5-5·0% of cases of hypoglycaemia and can be due either to β-cell tumours (insulinomas) or β-cell hyperplasia. Rapid diagnosis and prompt management of hyperinsulinaemic hypoglycaemia is essential to avoid hypoglycaemic brain injury, especially in the vulnerable neonatal and childhood periods. Advances in the field of hyperinsulinaemic hypoglycaemia include use of rapid molecular genetic testing for the disease, application of novel imaging techniques (6-[fluoride-18]fluoro-levodopa [18F-DOPA] PET-CT and glucagon-like peptide 1 (GLP-1) receptor imaging), and development of novel medical treatments (eg, long-acting octreotide formulations, mTOR inhibitors, and GLP-1 receptor antagonists) and surgical therapies (eg, laparoscopic surgery).
Collapse
Affiliation(s)
- Pratik Shah
- Genetics and Genomic Medicine Programme, University College London (UCL) Institute of Child Health, London, UK; Endocrinology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sofia A Rahman
- Genetics and Genomic Medicine Programme, University College London (UCL) Institute of Child Health, London, UK
| | - Huseyin Demirbilek
- Department of Paediatric Endocrinology, Hacettepe University, Ankara, Turkey
| | - Maria Güemes
- Genetics and Genomic Medicine Programme, University College London (UCL) Institute of Child Health, London, UK; Endocrinology Department, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Khalid Hussain
- Department of Pediatric Medicine, Sidra Medical & Research Center, Outpatient Clinic, Doha, Qatar.
| |
Collapse
|
35
|
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.
Collapse
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
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Helleskov A, Melikyan M, Globa E, Shcherderkina I, Poertner F, Larsen AM, Filipsen K, Brusgaard K, Christiansen CD, Hansen LK, Christesen HT. Both Low Blood Glucose and Insufficient Treatment Confer Risk of Neurodevelopmental Impairment in Congenital Hyperinsulinism: A Multinational Cohort Study. Front Endocrinol (Lausanne) 2017; 8:156. [PMID: 28740482 PMCID: PMC5502348 DOI: 10.3389/fendo.2017.00156] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 06/21/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND/AIMS Congenital hyperinsulinism (CHI) is a heterogeneous disease most frequently caused by KATP-channel (ABCC8 and KCNJ11) mutations, with neonatal or later onset, variable severity, and with focal or diffuse pancreatic involvement as the two major histological types. CHI confers a high risk of neurological impairment; however, sparsely studied in larger patient series. We assessed the neurodevelopmental outcome in children with CHI at follow-up in a mixed international cohort. METHODS In two hyperinsulinism expert centers, 75 CHI patients were included (Russian, n = 33, referred non-Scandinavian, treated in Denmark n = 27, Scandinavian, n = 15). Hospital files were reviewed. At follow-up, neurodevelopmental impairment and neurodevelopmental, cognitive and motor function scores were assessed. RESULTS Median (range) age at follow-up was 3.7 years (3.3 months-18.2 years). Neurodevelopmental impairment was seen in 35 (47%). Impairment was associated with abnormal brain magnetic resonance imaging (MRI); odds ratio (OR) (95% CI) 15.0 (3.0-74.3), p = 0.001; lowest recorded blood glucose ≤1 mmol/L; OR 3.8 (1.3-11.3), p = 0.015, being non-Scandinavian patient, OR 3.8 (1.2-11.9), p = 0.023; and treatment delay from first symptom to expert center >5 days; OR 4.0 (1.0-16.6), trend p = 0.05. In multivariate analysis (n = 31) for early predictors with exclusion of brain MRI, treatment delay from first symptom to expert center >5 days conferred a significantly increased risk of neurodevelopment impairment, adjusted OR (aOR) 15.6 (1.6-146.7), p = 0.016, while lowest blood glucose ≤1 mmol/L had a trend toward increased risk, aOR 3.5 (1.1-14.3), p = 0.058. No associations for early vs. late disease onset, KATP-channel mutations, disease severity, focal vs. diffuse disease, or age at follow-up were seen in uni- or multivariate analysis. CONCLUSION Not only very low blood glucose, but also insufficient treatment as expressed by delay until expert center hospitalization, increased the risk of neurodevelopmental impairment. This novel finding calls for improvements in spread of knowledge about CHI among health-care personnel and rapid contact with an expert CHI center on suspicion of CHI.
Collapse
Affiliation(s)
| | - Maria Melikyan
- Pediatric, Endocrinology Scientific Centre, Russian Academy of Science, Moscow, Russia
| | - Evgenia Globa
- Pediatric Endocrinology, Ukrainian Centre of Endocrine Surgery, Kyiv, Ukraine
| | | | - Fani Poertner
- Hans Christian Andersen Children’s Hospital, Odense, Denmark
| | | | - Karen Filipsen
- Hans Christian Andersen Children’s Hospital, Odense, Denmark
| | - Klaus Brusgaard
- Clinical Genetic Department, Odense University Hospital, Odense, Denmark
| | | | | | - Henrik T. Christesen
- Hans Christian Andersen Children’s Hospital, Odense, Denmark
- *Correspondence: Henrik T. Christesen,
| |
Collapse
|
38
|
Zhang JS, Li L, Cheng W. Single incision laparoscopic 90 % pancreatectomy for the treatment of persistent hyperinsulinemic hypoglycemia of infancy. Pediatr Surg Int 2016; 32:1003-7. [PMID: 27473008 DOI: 10.1007/s00383-016-3943-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/23/2016] [Indexed: 11/25/2022]
Abstract
Single incision laparoscopic surgery as a surgical approach in treatment of pancreatic disease has recently been reported in adults. However, its application in persistent hyperinsulinemic hypoglycemia of infancy (PHHI) in children is limited. In this article, we report single incision laparoscopic 90 % pancreatectomy for the treatment of persistent hyperinsulinemic hypoglycemia of infancy. Between July 2011 and February 2015, the single incision laparoscopic 90 % pancreatectomy was performed in three children with PHHI. All patients underwent (18)F-FDOPA PET/CT before the surgeries. The scans showed diffuse physiologic (18)F-FDOPA activity in entire pancreas. All patients were followed up. The levels of blood sugar and insulin were recorded postoperatively. The time required for surgery was 120-230 min, and blood loss was minimal. The hospital stay was 6 days. The duration of postoperative abdominal drainage was 4-5 days. The levels of fasting blood glucose after surgery were higher than those before surgery (4.38-8.9 vs. 0.54-1.8 mmol/L). The levels of fasting insulin after surgery were lower than those before surgery (2.4-5.5 vs. 14-33.3 uU/ml). The duration of follow-up was 4-46 months. During follow-up, the levels of blood glucose and insulin were normal in three patients. There was no recurrence of hypoglycemia after operation in all patients. Single incision laparoscopic 90 % pancreatectomy for children with PHHI is feasible and safe in well-selected cases in the experienced centers.
Collapse
Affiliation(s)
- Jin-Shan Zhang
- Department of General Surgery, Capital Institute of Pediatrics, No.2 Yabaolu Rd., Beijing, 100020, China
| | - Long Li
- Department of General Surgery, Capital Institute of Pediatrics, No.2 Yabaolu Rd., Beijing, 100020, China.
| | - Wei Cheng
- Department of Surgery, Beijing United Family Hospital, Beijing, China
- Department of Paediatrics, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Department of Surgery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| |
Collapse
|
39
|
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.
Collapse
Affiliation(s)
- Pratik Shah
- Developmental Endocrinology Research Group, Genetics and Genomic Medicine Programme, Institute of Child Health, University College London, London, UK
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Vora S, Chandran S, Rajadurai VS, Hussain K. Hyperinsulinemic Hypoglycemia in Infancy: Current Concepts in Diagnosis and Management. Indian Pediatr 2016; 52:1051-9. [PMID: 26713990 DOI: 10.1007/s13312-015-0772-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE Molecular basis of various forms of hyperinsulinemic hypoglycemia, involving defects in key genes regulating insulin secretion, are being increasingly reported. However, the management of medically unresponsive hyperinsulinism still remains a challenge as current facilities for genetic diagnosis and appropriate imaging are limited only to very few centers in the world. We aim to provide an overview of spectrum of clinical presentation, diagnosis and management of hyperinsulinism. METHODS We searched the Cochrane library, MEDLINE and EMBASE databases, and reference lists of identified studies. CONCLUSION Analysis of blood samples, collected at the time of hypoglycemic episodes, for intermediary metabolites and hormones is critical for diagnosis and treatment. Increased awareness among clinicians about infants at-risk of hypoglycemia, and recent advances in genetic diagnosis have made remarkable contribution to the diagnosis and management of hyperinsulinism. Newer drugs like lanreotide a long acting somatostatin analogue and sirolimus (mammalian target of rapamycin (mTOR) inhibitor) appears promising as patients with diffuse disease can be treated successfully without subtotal pancreatectomy, minimizing the long-term sequelae of diabetes and pancreatic insufficiency. Newer insights in understanding the molecular and histological basis and improvements in imaging and surgical techniques will modify the approach to patients with congenital hyperinsulinism.
Collapse
Affiliation(s)
- Shrenik Vora
- Department of Neonatology, KK Womens and Childrens Hospital, Singapore; and Genetics and Epigenetics in Health and Disease Genetics and Genomic Medicine Programme, UCL Institute of Child Health, Great Ormond Street Hospital for Children, 30 Guilford Street, London, UK. Correspondence to: Dr Shrenik Vora, Senior Staff Registrar, Department of Neonatology, KK Womens and Childrens Hospital, 100, Bukit Timah Road, Singapore 229899.
| | | | | | | |
Collapse
|
41
|
Kocaay P, Şiklar Z, Ellard S, Yagmurlu A, Çamtosun E, Erden E, Berberoglu M, Flanagan SE. Coexistence of Mosaic Uniparental Isodisomy and a KCNJ11 Mutation Presenting as Diffuse Congenital Hyperinsulinism and Hemihypertrophy. Horm Res Paediatr 2016; 85:421-5. [PMID: 27173951 PMCID: PMC5079068 DOI: 10.1159/000446153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/12/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Isolated hyperinsulinaemic hypoglycaemia (HH) commonly results from recessively inherited mutations in the ABCC8 and KCNJ11 genes that are located on chromosome 11p15.1. More rarely, HH can feature in patients with Beckwith-Wiedemann syndrome (BWS), a congenital overgrowth disorder, resulting from defects at a differentially methylated region telomeric to the K-ATP channel genes at chromosome 11p15.5. SUBJECT We undertook genetic testing in a patient with diazoxide-unresponsive HH diagnosed at birth. Physical examination later revealed hemihypertrophy of the right arm, a feature of BWS. RESULTS We identified a novel mosaic, paternally-inherited KCNJ11 mutation(s) in the patient. Further analysis confirmed uniparental disomy (UPD) of chromosome 11, which extended across the KCNJ11 gene at 11p15.1 and the BWS locus at 11p15.5. CONCLUSION These results highlight the importance of considering UPD as a mechanism of disease in patients with HH and a paternally inherited K-ATP channel mutation, especially when additional syndromic features are present.
Collapse
Affiliation(s)
- Pınar Kocaay
- Department of Pediatric Endocrinology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Şiklar
- Department of Pediatric Endocrinology, Ankara University Faculty of Medicine, Ankara, Turkey,*Dr. Zeynep Şiklar, Department of Pediatric Endocrinology, Ankara University Faculty of Medicine, Cigdem mahallesi 1577, TR-06520 Ankara (Turkey), E-Mail
| | - Sian Ellard
- Institute of Biomedicaland Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Aydın Yagmurlu
- Department of Pediatric Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Emine Çamtosun
- Department of Pediatric Endocrinology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Esra Erden
- Department of Pathology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Merih Berberoglu
- Department of Pediatric Endocrinology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Sarah E. Flanagan
- Institute of Biomedicaland Clinical Science, University of Exeter Medical School, Exeter, UK
| |
Collapse
|
42
|
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
|
43
|
Lachmann MJ, Salgin B, Kummer S, Welters A, Döing C, Zenker M, Wieland I, Mayatepek E, Meissner T. Remission of congenital hyperinsulinism following conservative treatment: an exploratory study in patients with KATP channel mutations. J Pediatr Endocrinol Metab 2016; 29:281-7. [PMID: 26581065 DOI: 10.1515/jpem-2015-0192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 09/25/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND During conservative treatment, congenital hyperinsulinism (CHI) can resolve spontaneously. This study describes the hormonal and metabolic profiles in three patients with ABCC8/KCNJ11 mutations in clinical remission. METHODS An age-adapted fasting and oral glucose tolerance test (OGTT) were performed. RESULTS All patients (aged 6-9 years) tolerated age-adapted fasting durations (20, respectively 24 h), without reaching glucose concentrations ≤2.5 mmol/L, nor developing hypoglycemia-related symptoms. Nevertheless, insulin concentrations from all patients exceeded the 90th reference percentile at the end of the fasting test (range: 4.2-15.8 mU/L). During the OGTT, one patient (patient 2; BMI: 23.4 kg/m2; age: 7 years) reached a glucose concentration of 11.4 mmol/L after 2 h (concomitant insulin concentration: 148.3 mU/L). CONCLUSIONS The insulin concentration profiles in CHI patients in apparent clinical remission range from almost complete normalization to persistent, yet attenuated, hypersecretion. The hyperglycemia, detected during the OGTT, must be further monitored.
Collapse
|
44
|
Nessa A, Rahman SA, Hussain K. Hyperinsulinemic Hypoglycemia - The Molecular Mechanisms. Front Endocrinol (Lausanne) 2016; 7:29. [PMID: 27065949 PMCID: PMC4815176 DOI: 10.3389/fendo.2016.00029] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/21/2016] [Indexed: 12/14/2022] Open
Abstract
Under normal physiological conditions, pancreatic β-cells secrete insulin to maintain fasting blood glucose levels in the range 3.5-5.5 mmol/L. In hyperinsulinemic hypoglycemia (HH), this precise regulation of insulin secretion is perturbed so that insulin continues to be secreted in the presence of hypoglycemia. HH may be due to genetic causes (congenital) or secondary to certain risk factors. The molecular mechanisms leading to HH involve defects in the key genes regulating insulin secretion from the β-cells. At this moment, in time genetic abnormalities in nine genes (ABCC8, KCNJ11, GCK, SCHAD, GLUD1, SLC16A1, HNF1A, HNF4A, and UCP2) have been described that lead to the congenital forms of HH. Perinatal stress, intrauterine growth retardation, maternal diabetes mellitus, and a large number of developmental syndromes are also associated with HH in the neonatal period. In older children and adult's insulinoma, non-insulinoma pancreatogenous hypoglycemia syndrome and post bariatric surgery are recognized causes of HH. This review article will focus mainly on describing the molecular mechanisms that lead to unregulated insulin secretion.
Collapse
Affiliation(s)
- Azizun Nessa
- Genetics and Genomic Medicine Programme, Department of Paediatric Endocrinology, UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS, London, UK
| | - Sofia A. Rahman
- Genetics and Genomic Medicine Programme, Department of Paediatric Endocrinology, UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS, London, UK
| | - Khalid Hussain
- Genetics and Genomic Medicine Programme, Department of Paediatric Endocrinology, UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS, London, UK
- *Correspondence: Khalid Hussain,
| |
Collapse
|
45
|
Mussa A, Di Candia S, Russo S, Catania S, De Pellegrin M, Di Luzio L, Ferrari M, Tortora C, Meazzini MC, Brusati R, Milani D, Zampino G, Montirosso R, Riccio A, Selicorni A, Cocchi G, Ferrero GB. Recommendations of the Scientific Committee of the Italian Beckwith-Wiedemann Syndrome Association on the diagnosis, management and follow-up of the syndrome. Eur J Med Genet 2015; 59:52-64. [PMID: 26592461 DOI: 10.1016/j.ejmg.2015.11.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 11/03/2015] [Accepted: 11/17/2015] [Indexed: 01/10/2023]
Abstract
UNLABELLED Beckwith-Wiedemann syndrome (BWS) is the most common (epi)genetic overgrowth-cancer predisposition disorder. Given the absence of consensual recommendations or international guidelines, the Scientific Committee of the Italian BWS Association (www.aibws.org) proposed these recommendations for the diagnosis, molecular testing, clinical management, follow-up and tumor surveillance of patients with BWS. The recommendations are intended to allow a timely and appropriate diagnosis of the disorder, to assist patients and their families, to provide clinicians and caregivers optimal strategies for an adequate and satisfactory care, aiming also at standardizing clinical practice as a national uniform approach. They also highlight the direction of future research studies in this setting. With recent advances in understanding the disease (epi)genetic mechanisms and in describing large cohorts of BWS patients, the natural history of the disease will be dissected. In the era of personalized medicine, the emergence of specific (epi)genotype-phenotype correlations in BWS will likely lead to differentiated follow-up approaches for the molecular subgroups, to the development of novel tools to evaluate the likelihood of cancer development and to the refinement and optimization of current tumor screening strategies. CONCLUSIONS In this article, we provide the first comprehensive recommendations on the complex management of patients with Beckwith-Wiedemann syndrome.
Collapse
Affiliation(s)
- Alessandro Mussa
- Department of Public Health and Pediatric Sciences, University of Torino, Torino, Italy.
| | - Stefania Di Candia
- Department of Pediatrics, San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Russo
- Laboratory of Cytogenetics and Molecular Genetics, Istituto Auxologico Italiano, Milan, Italy
| | - Serena Catania
- Pediatric Oncology Unit, Department of Hematology and Pediatric Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | | | - Luisa Di Luzio
- Obstetrics and Gynecology Unit, Niguarda Hospital, Milan, Italy
| | - Mario Ferrari
- Regional Center for CLP, Smile-House, San Paolo University Hospital, Milan, Italy
| | - Chiara Tortora
- Regional Center for CLP, Smile-House, San Paolo University Hospital, Milan, Italy
| | | | - Roberto Brusati
- Regional Center for CLP, Smile-House, San Paolo University Hospital, Milan, Italy
| | - Donatella Milani
- Pediatric Highly Intensive Care Unit, Department of Pathophysiology and Transplantation, Università degli Studi di Milano Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Zampino
- Center for Rare Diseases, Department of Pediatrics, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rosario Montirosso
- 0-3 Center for the Study of Social Emotional Development of the at Risk Infant, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Andrea Riccio
- DiSTABiF, Second University of Naples and Institute of Genetics and Biophysics "A. Buzzati-Traverso" - CNR, Naples, Italy
| | - Angelo Selicorni
- Clinical Pediatric Genetics Unit, Pediatrics Clinics, MBBM Foundation, S. Gerardo Hospital, Monza, Italy
| | - Guido Cocchi
- GC Department of Pediatrics, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | | |
Collapse
|
46
|
Méder Ü, Bokodi G, Balogh L, Körner A, Szabó M, Pruhova S, Szabó AJ. Severe Hyperinsulinemic Hypoglycemia in a Neonate: Response to Sirolimus Therapy. Pediatrics 2015; 136:e1369-72. [PMID: 26504129 DOI: 10.1542/peds.2014-4200] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Hyperinsulinemic hypoglycemia (HH) is one of the most common causes of persistent hypoglycemic episodes in neonates. Current pharmacologic treatment of neonatal HH includes diazoxide and octreotide, whereas for diffuse, unresponsive cases a subtotal pancreatectomy may be the last resort, with questionable efficacy. Here we report a case of congenital diffuse neonatal HH, first suspected when severe hypoglycemia presented with extremely high serum insulin levels immediately after birth. Functional imaging and genetic tests later confirmed the diagnosis. Failure to respond to a sequence of different treatments and to avoid extensive surgery with predictable morbidity prompted us to introduce a recently suggested alternative therapy with sirolimus, a mammalian target of rapamycin inhibitor. Glucose intake could be reduced gradually while euglycemia was maintained, and we were able to achieve exclusively enteral feeding within 6 weeks. Sirolimus was found to be effective and well tolerated, with no major adverse side effects attributable to its administration.
Collapse
Affiliation(s)
- Ünőke Méder
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary;
| | - Géza Bokodi
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Lídia Balogh
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Anna Körner
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Miklós Szabó
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Stepanka Pruhova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, Czech Republic; and
| | - Attila J Szabó
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary; Pediatrics and Nephrology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| |
Collapse
|
47
|
Soheilipour F, Jesmi F, Ahmadi M, Pazouki A, Alibeigi P, Abdolhosseini M. Minimally invasive surgical interventions in the treatment of primary persistent hyperinsulinemic hypoglycemia of infancy. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2015; 59:466-9. [PMID: 26331229 DOI: 10.1590/2359-3997000000094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 04/20/2015] [Indexed: 11/22/2022]
Abstract
Hyperinsulinemia, diagnosed by laboratory tests, should be diagnosed and treated as soon as possible to prevent fatal complications such as neurological damage. Patients who are resistant to medical therapy should be treated surgically. Minimally invasive surgery, a newly developed approach, is a good choice among surgical procedures to avoid unnecessary extensive pancreatectomy. Here, a 12-year-old boy is presented with diagnosis of hyperinsulinemic hypoglycemia who had recurrent attacks of hypoglycemia and seizures from infancy. Because of his unresponsiveness to medical therapy and his family's preference, he underwent laparoscopic pancreatectomy to reduce morbidity and hospital stay. Two years postsurgical follow-up revealed a normo-glycemic state.
Collapse
Affiliation(s)
- Fahimeh Soheilipour
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Jesmi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Ahmadi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Abdolreza Pazouki
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Peyman Alibeigi
- Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | |
Collapse
|
48
|
Senniappan S, Sadeghizadeh A, Flanagan SE, Ellard S, Hashemipour M, Hosseinzadeh M, Salehi M, Hussain K. Genotype and phenotype correlations in Iranian patients with hyperinsulinaemic hypoglycaemia. BMC Res Notes 2015; 8:350. [PMID: 26268944 PMCID: PMC4535259 DOI: 10.1186/s13104-015-1319-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 08/04/2015] [Indexed: 01/19/2023] Open
Abstract
Background Hyperinsulinaemic hypoglycaemia (HH) is a group of clinically and genetically heterogeneous disorders characterized by unregulated insulin secretion. Abnormalities in nine different genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, HNF4A, UCP2 and HNF1A) have been reported in HH, the most common being ABCC8 and KCNJ11. We describe the genetic aetiology and phenotype of Iranian patients with HH. Methods Retrospective clinical, biochemical and genetic information was collected on 23 patients with biochemically confirmed HH. Mutation analysis was carried out for the ATP-sensitive potassium (KATP) channel genes (ABCC8 and KCNJ11), GLUD1, GCK, HADH and HNF4A. Results 78 % of the patients were identified to have a genetic cause for HH. 48 % of patients had mutation in HADH, whilst ABCC8/KCNJ11 mutations were identified in 30 % of patients. Among the diazoxide-responsive patients (18/23), mutations were identified in 72 %. These include two novel homozygous ABCC8 mutations. Of the five patients with diazoxide-unresponsive HH, three had homozygous ABCC8 mutation, one had heterozygous ABCC8 mutation inherited from an unaffected father and one had homozygous KCNJ11 mutation. 52 % of children in our cohort were born to consanguineous parents. Patients with ABCC8/KCNJ11 mutations were noted to be significantly heavier than those with HADH mutation (p = 0.002). Our results revealed neurodevelopmental deficits in 30 % and epilepsy in 52 % of all patients. Conclusions To the best of our knowledge, this is the first study of its kind in Iran. We found disease-causing mutations in 78 % of HH patients. The predominance of HADH mutation might be due to a high incidence of consanguineous marriage in this population. Further research involving a larger cohort of HH patients is required in Iranian population.
Collapse
Affiliation(s)
| | - Atefeh Sadeghizadeh
- Department of Pediatrics, Child Growth and Development Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Sarah E Flanagan
- Institute Biomedical and Clinical Science, University of Exeter Medical School, Exeter, EX2 5DW, UK.
| | - Sian Ellard
- Institute Biomedical and Clinical Science, University of Exeter Medical School, Exeter, EX2 5DW, UK.
| | - Mahin Hashemipour
- Endocrinology and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Majid Hosseinzadeh
- Medical Genetics Laboratory, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Mansour Salehi
- Pediatric Inherited Disease Research Center (PIDRC), Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Khalid Hussain
- Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London, London, UK. .,Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London, UK.
| |
Collapse
|
49
|
Abstract
In hyperinsulinemic hypoglycemia (HH) there is dysregulation of insulin secretion from pancreatic β-cells. Insulin secretion becomes inappropriate for the level of blood glucose leading to severe hypoglycemia. HH is associated with a high risk of brain injury because insulin inhibits lipolysis and ketogenesis thus preventing the generation of alternative brain substrates (such as ketone bodies). Hence HH must be diagnosed as soon as possible and the management instituted appropriately to prevent brain damage. This article reviews the mechanisms of glucose physiology in the newborn, the mechanisms of insulin secretion, the etiologic types of HH, and its management.
Collapse
Affiliation(s)
- Maria Güemes
- Developmental Endocrinology Research Group, Molecular Genetics Unit, Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK
| | - Khalid Hussain
- Developmental Endocrinology Research Group, Molecular Genetics Unit, Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK.
| |
Collapse
|
50
|
Brady C, Palladino AA, Gutmark-Little I. A novel case of compound heterozygous congenital hyperinsulinism without high insulin levels. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2015; 2015:16. [PMID: 26180531 PMCID: PMC4502541 DOI: 10.1186/s13633-015-0012-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 07/01/2015] [Indexed: 11/24/2022]
Abstract
Background Congenital hyperinsulinism leads to unregulated insulin secretion and hypoglycemia. Diagnosis can be difficult and genetic testing may be warranted. Case This patient initially presented at 11 months with seizure activity secondary to severe hypoglycemia. Her diagnostic evaluation included genetic studies, which confirmed congenital hyperinsulinism. A novel combination of mutations in the ABCC8 gene leading to diffuse, diazoxide-unresponsive congenital hyperinsulinism was identified. Mutation analysis of ABCC8 showed three variants (R1215W – paternal, pathogenic; W739C – maternal, variant of unknown significance; R1393L – maternal, variant of unknown significance). Her clinical course continues to be complicated by severe, refractory hypoglycemia at age 3 years. Conclusion We describe a novel compound heterozygous mutation leading to diffuse, diazoxide-unresponsive congenital hyperinsulinism. This case illustrates challenges associated with diagnosing and managing congenital hyperinsulinism and the importance of genetic testing.
Collapse
Affiliation(s)
- Cassandra Brady
- Cincinnati Children's Hospital Medical Center, Division of Endocrinology, 3333 Burnet Ave, MLC 7012, Cincinnati, OH 45229 USA
| | - Andrew A Palladino
- Children's Hospital of Philadelphia, Division of Endocrinology, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Iris Gutmark-Little
- Cincinnati Children's Hospital Medical Center, Division of Endocrinology, 3333 Burnet Ave, MLC 7012, Cincinnati, OH 45229 USA
| |
Collapse
|