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Rossini G, Risi R, Monte L, Sancetta B, Quadrini M, Ugoccioni M, Masi D, Rossetti R, D'Alessio R, Mazzilli R, Defeudis G, Lubrano C, Gnessi L, Watanabe M, Manfrini S, Tuccinardi D. Postbariatric surgery hypoglycemia: Nutritional, pharmacological and surgical perspectives. Diabetes Metab Res Rev 2024; 40:e3750. [PMID: 38018334 DOI: 10.1002/dmrr.3750] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/09/2023] [Accepted: 11/03/2023] [Indexed: 11/30/2023]
Abstract
Post-bariatric hypoglycaemia (PBH) is a metabolic complication of bariatric surgery (BS), consisting of low post-prandial glucose levels in patients having undergone bariatric procedures. While BS is currently the most effective and relatively safe treatment for obesity and its complications, the development of PBH can significantly impact patients' quality of life and mental health. The diagnosis of PBH is still challenging, considering the lack of definitive and reliable diagnostic tools, and the fact that this condition is frequently asymptomatic. However, PBH's prevalence is alarming, involving up to 88% of the post-bariatric population, depending on the diagnostic tool, and this may be underestimated. Given the prevalence of obesity soaring, and an increasing number of bariatric procedures being performed, it is crucial that physicians are skilled to diagnose PBH and promptly treat patients suffering from it. While the milestone of managing this condition is nutritional therapy, growing evidence suggests that old and new pharmacological approaches may be adopted as adjunct therapies for managing this complex condition.
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Affiliation(s)
- Giovanni Rossini
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Renata Risi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Lavinia Monte
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Biagio Sancetta
- Department of Medicine, Unit of Neurology, Neurophysiology, Neurobiology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Maria Quadrini
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Massimiliano Ugoccioni
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Davide Masi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Rebecca Rossetti
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Rossella Mazzilli
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Defeudis
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Carla Lubrano
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Lucio Gnessi
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Mikiko Watanabe
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Silvia Manfrini
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
| | - Dario Tuccinardi
- Department of Endocrinology and Diabetes, University Campus Bio-Medico of Rome, Rome, Italy
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Alam KA, Svalastoga P, Martinez A, Glennon JC, Haavik J. Potassium channels in behavioral brain disorders. Molecular mechanisms and therapeutic potential: A narrative review. Neurosci Biobehav Rev 2023; 152:105301. [PMID: 37414376 DOI: 10.1016/j.neubiorev.2023.105301] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 06/26/2023] [Accepted: 06/30/2023] [Indexed: 07/08/2023]
Abstract
Potassium channels (K+-channels) selectively control the passive flow of potassium ions across biological membranes and thereby also regulate membrane excitability. Genetic variants affecting many of the human K+-channels are well known causes of Mendelian disorders within cardiology, neurology, and endocrinology. K+-channels are also primary targets of many natural toxins from poisonous organisms and drugs used within cardiology and metabolism. As genetic tools are improving and larger clinical samples are being investigated, the spectrum of clinical phenotypes implicated in K+-channels dysfunction is rapidly expanding, notably within immunology, neurosciences, and metabolism. K+-channels that previously were considered to be expressed in only a few organs and to have discrete physiological functions, have recently been found in multiple tissues and with new, unexpected functions. The pleiotropic functions and patterns of expression of K+-channels may provide additional therapeutic opportunities, along with new emerging challenges from off-target effects. Here we review the functions and therapeutic potential of K+-channels, with an emphasis on the nervous system, roles in neuropsychiatric disorders and their involvement in other organ systems and diseases.
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Affiliation(s)
| | - Pernille Svalastoga
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway; Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | | | - Jeffrey Colm Glennon
- Conway Institute for Biomolecular and Biomedical Research, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Jan Haavik
- Department of Biomedicine, University of Bergen, Norway; Division of Psychiatry, Haukeland University Hospital, Norway.
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Muacevic A, Adler JR, P. Murthi S, Alsaffar H, Al Mandhari H. Predictors of the Need to Use Medications in the Management of Neonatal Hypoglycemia. Cureus 2022; 14:e32197. [PMID: 36620829 PMCID: PMC9811335 DOI: 10.7759/cureus.32197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
Background and objective Neonatal hypoglycemia (NH) is one of the most common causes of admission to the neonatal intensive care unit (NICU). Persistent NH despite adequate feeding and intravenous dextrose may often require medications to maintain normal blood glucose levels (BGL). Several medications are used in the management of persistent NH, such as glucagon, diazoxide, and octreotide. In this study, we aimed to determine the factors that predict the need for medications to treat persistent NH. Methods This was a retrospective cohort study conducted at the Sultan Qaboos University Hospital (SQUH), Muscat, Oman. Infants admitted to the NICU between 2015 and 2019 with hypoglycemia (capillary blood glucose <2.6 mmol/l) were eligible to be included in the study. A prespecified dataset was collected from electronic patient records, including birth weight (BW), APGAR scores, gestational age, BGL, maternal risk factors such as diabetes mellitus (DM), hypertension, or antenatal use of medications, and the NICU management during admission. Data analysis was performed using SPSS Statistics for Windows, version 27.0 (IBM Corp., Armonk, NY). Results A total of 89 neonates were admitted due to NH during the study period. Of them, 10 (11.2%) patients had received medication (diazoxide). Use of medication for persistent NH was significantly associated with maternal gestational diabetes/diabetes mellitus (GDM/DM) status (p=0.041), higher BW (p=0.001), and large for gestational age [LGA (defined as BW >90th percentile)] (p=0.014), severe hypoglycemia (mean glucose level of 1-1.5 mmol/l) at two hours of life and at admission, and elevated maximum glucose infusion rate (GIR). GIR for the medication-requiring cohort was 12.95 mg/kg/min and that for the non-medication-requiring cohort was 6.77 mg/kg/min (p<0.001). Conclusion Based on our findings, the need for using certain medications to treat persistent NH, such as diazoxide in neonates admitted with NH, can be predicted by factors such as maternal GDM/DM status, BW >90th percentile, very low BGL at two hours of age and on admission, and elevated GIR. Elevated maximum GIR was a leading indicator for using medications in the treatment of NH.
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4
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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.
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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: 41] [Impact Index Per Article: 10.3] [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.
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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.
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Sikimic J, Hoffmeister T, Gresch A, Kaiser J, Barthlen W, Wolke C, Wieland I, Lendeckel U, Krippeit-Drews P, Düfer M, Drews G. Possible New Strategies for the Treatment of Congenital Hyperinsulinism. Front Endocrinol (Lausanne) 2020; 11:545638. [PMID: 33193079 PMCID: PMC7653201 DOI: 10.3389/fendo.2020.545638] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 10/02/2020] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Congenital hyperinsulinism (CHI) is a rare disease characterized by persistent hypoglycemia as a result of inappropriate insulin secretion, which can lead to irreversible neurological defects in infants. Poor efficacy and strong adverse effects of the current medications impede successful treatment. The aim of the study was to investigate new approaches to silence β-cells and thus attenuate insulin secretion. RESEARCH DESIGN AND METHODS In the scope of our research, we tested substances more selective and more potent than the gold standard diazoxide that also interact with neuroendocrine ATP-sensitive K+ (KATP) channels. Additionally, KATP channel-independent targets as Ca2+-activated K+ channels of intermediate conductance (KCa3.1) and L-type Ca2+ channels were investigated. Experiments were performed using human islet cell clusters isolated from tissue of CHI patients (histologically classified as pathological) and islet cell clusters obtained from C57BL/6N (WT) or SUR1 knockout (SUR1-/-) mice. The cytosolic Ca2+ concentration ([Ca2+]c) was used as a parameter for the pathway regulated by electrical activity and was determined by fura-2 fluorescence. The mitochondrial membrane potential (ΔΨ) was determined by rhodamine 123 fluorescence and single channel currents were measured by the patch-clamp technique. RESULTS The selective KATP channel opener NN414 (5 µM) diminished [Ca2+]c in isolated human CHI islet cell clusters and WT mouse islet cell clusters stimulated with 10 mM glucose. In islet cell clusters lacking functional KATP channels (SUR1-/-) the drug was without effect. VU0071063 (30 µM), another KATP channel opener considered to be selective, lowered [Ca2+]c in human CHI islet cell clusters. The compound was also effective in islet cell clusters from SUR1-/- mice, showing that [Ca2+]c is influenced by additional effects besides KATP channels. Contrasting to NN414, the drug depolarized ΔΨ in murine islet cell clusters pointing to severe interference with mitochondrial metabolism. An opener of KCa3.1 channels, DCEBIO (100 µM), significantly decreased [Ca2+]c in SUR1-/- and human CHI islet cell clusters. To target L-type Ca2+ channels we tested two already approved drugs, dextromethorphan (DXM) and simvastatin. DXM (100 µM) efficiently diminished [Ca2+]c in stimulated human CHI islet cell clusters as well as in stimulated SUR1-/- islet cell clusters. Similar effects on [Ca2+]c were observed in experiments with simvastatin (7.2 µM). CONCLUSIONS NN414 seems to provide a good alternative to the currently used KATP channel opener diazoxide. Targeting KCa3.1 channels by channel openers or L-type Ca2+ channels by DXM or simvastatin might be valuable approaches for treatment of CHI caused by mutations of KATP channels not sensitive to KATP channel openers.
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Affiliation(s)
- Jelena Sikimic
- Department of Pharmacology, Institute of Pharmacy, University of Tübingen, Tübingen, Germany
| | - Theresa Hoffmeister
- Department of Pharmacology, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Münster, Germany
| | - Anne Gresch
- Department of Pharmacology, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Münster, Germany
| | - Julia Kaiser
- Department of Pharmacology, Institute of Pharmacy, University of Tübingen, Tübingen, Germany
| | - Winfried Barthlen
- Department of Pediatric Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Carmen Wolke
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald, Germany
| | - Ilse Wieland
- Institute of Human Genetics, University Hospital Magdeburg, Magdeburg, Germany
| | - Uwe Lendeckel
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Greifswald, Germany
| | - Peter Krippeit-Drews
- Department of Pharmacology, Institute of Pharmacy, University of Tübingen, Tübingen, Germany
- *Correspondence: Peter Krippeit-Drews,
| | - Martina Düfer
- Department of Pharmacology, Institute of Pharmaceutical and Medicinal Chemistry, University of Münster, Münster, Germany
| | - Gisela Drews
- Department of Pharmacology, Institute of Pharmacy, University of Tübingen, Tübingen, Germany
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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.
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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
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Ames A, Lago-Hernandez CA, Grunvald E. Hypoglycemia After Gastric Bypass Successfully Treated With Calcium Channel Blockers: Two Case Reports. J Endocr Soc 2019; 3:1417-1422. [PMID: 31286108 PMCID: PMC6608552 DOI: 10.1210/js.2019-00097] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 05/22/2019] [Indexed: 12/14/2022] Open
Abstract
Postprandial hyperinsulinemic hypoglycemia is an uncommon yet well-established complication of Roux-en-Y gastric bypass (RYGB) that can result in serious morbidity and adversely affect quality of life. It is often unrecognized and may be difficult to diagnose. Management is challenging. As the number of bariatric procedures increases in parallel with the obesity epidemic, clinicians will be tasked to offer effective medical therapies for this complication. Two patients presented several years after RYGB with severe postprandial hypoglycemia. In one of the patients, we were able to document simultaneous postprandial hypoglycemia and hyperinsulinemia. Conventional treatment approaches, including medical nutrition therapy, acarbose, diazoxide, and octreotide, were either ineffective or limited by poor tolerance. Nifedipine and verapamil were used adjunctively with dietary modification, resulting in resolution of symptomatic hypoglycemic episodes. These agents are therapeutic options that can be used for some patients refractory to more traditional treatments. They should be tried before surgical procedures are considered for affected patients. These two cases demonstrate that calcium channel blockers may be efficacious and appropriate for select patients refractory to dietary interventions alone.
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Affiliation(s)
- Angharad Ames
- School of Medicine, University of California, San Diego, California.,Department of Psychiatry, University of California, Riverside, California
| | | | - Eduardo Grunvald
- School of Medicine, University of California, San Diego, California.,Bariatric and Metabolic Institute, Division of Minimally Invasive Surgery, Department of Surgery, University of California, San Diego, California.,Division of General Internal Medicine, Department of Medicine, University of California, San Diego, California
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Kallem VR, Pandita A, Gupta G. Hypoglycemia: When to Treat? Clin Med Insights Pediatr 2017; 11:1179556517748913. [PMID: 29276423 PMCID: PMC5734558 DOI: 10.1177/1179556517748913] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 11/26/2017] [Indexed: 11/16/2022] Open
Abstract
Hypoglycemia is the most common metabolic disorder encountered in neonates. The definition of hypoglycemia as well as its clinical significance and management remain controversial. Most cases of neonatal hypoglycemia are transient, respond readily to treatment, and are associated with an excellent prognosis. Persistent hypoglycemia is more likely to be associated with abnormal endocrine conditions, such as hyperinsulinemia, as well as possible neurologic sequelae. Manifestations of hypoglycemia include seizures which can result in noteworthy neuromorbidity in the long haul. Thus, hypoglycemia constitutes a neonatal emergency which requires earnest analytic assessment and prompt treatment. In this review, we have tried to cover the pathophysiology, the screening protocol for high-risk babies, management, long-term neurologic sequelae associated with neonatal hypoglycemia, with evidence-based answers wherever possible, and our own practices.
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Affiliation(s)
| | - Aakash Pandita
- Department of Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Girish Gupta
- Department of Neonatology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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10
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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.
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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:
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11
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Sharma A, Davis A, Shekhawat PS. Hypoglycemia in the preterm neonate: etiopathogenesis, diagnosis, management and long-term outcomes. Transl Pediatr 2017; 6:335-348. [PMID: 29184814 PMCID: PMC5682372 DOI: 10.21037/tp.2017.10.06] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Glucose, like oxygen, is of fundamental importance for any living being and it is the major energy source for the fetus and the neonate during gestation. The placenta ensures a steady supply of glucose to the fetus, while birth marks a sudden change in substrate delivery and a major change in metabolism. Hypoglycemia is one of the most common pathologies encountered in the neonatal intensive care unit and affects a wide range of neonates. Preterm, small for gestational age (GA) and intra-uterine growth restricted neonates are especially vulnerable due to their lack of metabolic reserves and associated co-morbidities. Nearly 30-60% of these high-risk infants are hypoglycemic and require immediate intervention. Preterm neonates are uniquely predisposed to developing hypoglycemia and its associated complications due to their limited glycogen and fat stores, inability to generate new glucose using gluconeogenesis pathways, have higher metabolic demands due to a relatively larger brain size, and are unable to mount a counter-regulatory response to hypoglycemia. In this review we will discuss the epidemiology; pathophysiology; clinical presentation; management and neurodevelopmental outcomes in affected infants and summarize evidence to develop a rational and scientific approach to this common problem.
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Affiliation(s)
- Anudeepa Sharma
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ajuah Davis
- Division of Pediatric Endocrinology, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Prem S Shekhawat
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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Demirbilek H, Rahman SA, Buyukyilmaz GG, Hussain K. Diagnosis and treatment of hyperinsulinaemic hypoglycaemia and its implications for paediatric endocrinology. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2017; 2017:9. [PMID: 28855921 PMCID: PMC5575922 DOI: 10.1186/s13633-017-0048-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/15/2017] [Indexed: 12/14/2022]
Abstract
Glucose homeostasis requires appropriate and synchronous coordination of metabolic events and hormonal activities to keep plasma glucose concentrations in a narrow range of 3.5–5.5 mmol/L. Insulin, the only glucose lowering hormone secreted from pancreatic β-cells, plays the key role in glucose homeostasis. Insulin release from pancreatic β-cells is mainly regulated by intracellular ATP-generating metabolic pathways. Hyperinsulinaemic hypoglycaemia (HH), the most common cause of severe and persistent hypoglycaemia in neonates and children, is the inappropriate secretion of insulin which occurs despite low plasma glucose levels leading to severe and persistent hypoketotic hypoglycaemia. Mutations in 12 different key genes (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A, HNF1A, HK1, PGM1 and PMM2) constitute the underlying molecular mechanisms of congenital HH. Since insulin supressess ketogenesis, the alternative energy source to the brain, a prompt diagnosis and immediate management of HH is essential to avoid irreversible hypoglycaemic brain damage in children. Advances in molecular genetics, imaging methods (18F–DOPA PET-CT), medical therapy and surgical approach (laparoscopic and open pancreatectomy) have changed the management and improved the outcome of patients with HH. This up to date review article provides a background to the diagnosis, molecular genetics, recent advances and therapeutic options in the field of HH in children.
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Affiliation(s)
- Huseyin Demirbilek
- Department of Paediatric Endocrinology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Sofia A Rahman
- Great Ormond Street Institute of Child Health, Genetics and Genomic Medicine, University College London, 30 Guilford Street, London, WC1N 1EH UK
| | - Gonul Gulal Buyukyilmaz
- Department of Paediatric Endocrinology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Khalid Hussain
- Department of Paediatric Medicine Sidra Medical & Research Center, OPC, C6-337, PO Box 26999, Doha, Qatar
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Yorifuji T, Horikawa R, Hasegawa T, Adachi M, Soneda S, Minagawa M, Ida S, Yonekura T, Kinoshita Y, Kanamori Y, Kitagawa H, Shinkai M, Sasaki H, Nio M. Clinical practice guidelines for congenital hyperinsulinism. Clin Pediatr Endocrinol 2017; 26:127-152. [PMID: 28804205 PMCID: PMC5537210 DOI: 10.1297/cpe.26.127] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 03/08/2017] [Indexed: 12/11/2022] Open
Abstract
Congenital hyperinsulinism is a rare condition, and following recent advances in
diagnosis and treatment, it was considered necessary to formulate evidence-based clinical
practice guidelines reflecting the most recent progress, to guide the practice of
neonatologists, pediatric endocrinologists, general pediatricians, and pediatric surgeons.
These guidelines cover a range of aspects, including general features of congenital
hyperinsulinism, diagnostic criteria and tools for diagnosis, first- and second-line
medical treatment, criteria for and details of surgical treatment, and future
perspectives. These guidelines were generated as a collaborative effort between The
Japanese Society for Pediatric Endocrinology and The Japanese Society of Pediatric
Surgeons, and followed the official procedures of guideline generation to identify
important clinical questions, perform a systematic literature review (April 2016), assess
the evidence level of each paper, formulate the guidelines, and obtain public
comments.
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Affiliation(s)
- Tohru Yorifuji
- Division of Pediatric Endocrinology and Metabolism, Children's Medical Center, Osaka City General Hospital, Osaka, Japan
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | | | - Masanori Adachi
- Department of Endocrinology and Metabolism, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Shun Soneda
- Department of Pediatrics, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | - Shinobu Ida
- Department of Pediatric Gastroenterology, Nutrition and Endocrinology, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Takeo Yonekura
- Department of Pediatric Surgery, Nara Hospital, Kindai University Faculty of Medicine, Nara, Japan
| | - Yoshiaki Kinoshita
- Department of Pediatric Surgery, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yutaka Kanamori
- Department of Surgery, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroaki Kitagawa
- Division of Pediatric Surgery, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, Kanagawa, Japan
| | - Hideyuki Sasaki
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
| | - Masaki Nio
- Department of Pediatric Surgery, Tohoku University, Miyagi, Japan
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Abstract
Congenital hyperinsulinism (CHI) is a rare disease characterized by dysregulated insulin secretion from pancreatic β-cells. Recurrent hypoglycemia can lead to neurological insult and permanent brain injury. Recently, there are important advances in understanding the genetic mechanisms, histological characteristics, imaging, and surgical techniques of congenital hyperinsulinemic hypoglycemia that could reflect to improvement in the clinical care of infants with this disorder. In Turkey, there is a high rate of consanguinity, thus, the incidence of CHI is expected to be high. Until now, there are no nationwide data regarding the disorder, and some individual case reports or case series had been published. Determining the characteristics of Turkish patients with CHI can help develop a different perspective on this rare disease. In this review, we evaluated the clinical and molecular characteristics of Turkish patients with CHI based on reports published in the literature. The most frequently seen mutations were ABCC8 gene mutations (n=37), followed by HADH (n=11) and KCNJ11 gene (n=7) mutations. A total of 141 Turkish patients with CHI were reported until now. Among them, 115 patients had been genetically analyzed, and 56 of them had one of the mutation leading to hyperinsulinism.
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Affiliation(s)
- Zeynep Şıklar
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey, Phone: +90 312 595 66 35 E-mail:
| | - Merih Berberoğlu
- Ankara University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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Park JS, Lee HJ, Park CH. A novel mutation of ABCC8 gene in a patient with diazoxide-unresponsive congenital hyperinsulinism. KOREAN JOURNAL OF PEDIATRICS 2016; 59:S116-S120. [PMID: 28018462 PMCID: PMC5177692 DOI: 10.3345/kjp.2016.59.11.s116] [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: 08/21/2014] [Revised: 09/15/2014] [Accepted: 09/25/2014] [Indexed: 12/04/2022]
Abstract
Congenital hyperinsulinism (CHI) is a rare condition that can cause irreversible brain damage during the neonatal period owing to the associated hypoglycemia. Hypoglycemia in CHI occurs secondary to the dysregulation of insulin secretion. CHI has been established as a genetic disorder of islet-cell hyperplasia, associated with a mutation of the ABCC8 or KCNJ11 genes, which encode the sulfonylurea receptor 1 and the inward rectifying potassium channel (Kir6.2) subunit of the ATP-sensitive potassium channel, respectively. We report the case of a female newborn infant who presented with repetitive seizures and episodes of apnea after birth, because of hypoglycemia. Investigations revealed hypoglycemia with hyperinsulinemia, but no ketone bodies, and a low level of free fatty acids. High dose glucose infusion, enteral feeding, and medications could not maintain the patient's serum glucose level. Genetic testing revealed a new variation of ABCC8 mutation. Therefore, we report this case of CHI caused by a novel mutation of ABCC8 in a half-Korean newborn infant with diazoxide-unresponsive hyperinsulinemic hypoglycemia.
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Affiliation(s)
- Ji Sook Park
- Department of Pediatrics, Gyeongsang National Unviersity School of Medicine, Jinju, Korea
| | - Hong-Jun Lee
- Department of Pediatrics, Gyeongsang National Unviersity School of Medicine, Jinju, Korea
| | - Chan-Hoo Park
- Department of Pediatrics, Gyeongsang National Unviersity School of Medicine, Jinju, Korea
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Mordes JP, Alonso LC. Evaluation, Medical Therapy, and Course of Adult Persistent Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass Surgery: A Case Series. Endocr Pract 2016; 21:237-46. [PMID: 25100376 DOI: 10.4158/ep14118.or] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To describe the evaluation and treatment of hyperinsulinemic hypoglycemia in adults who had undergone gastric bypass surgery. A small number of patients who undergo Roux-en-Y bypass surgery develop postprandial hypoglycemia in the absence of dumping. In some cases, such patients have been treated with pancreatectomy. METHODS We report the demographics, diagnostic results, response to medical therapy, and subsequent course of 6 referral patients with post-Roux-en-Y gastric bypass hypoglycemia. RESULTS Characteristic clinical and metabolic parameters consistent with hyperinsulinemic hypoglycemia were identified. Parameters were similar for both spontaneous and glucose-challenge-induced hypoglycemia. In the context of exclusively postprandial symptoms, simultaneous glucose ≤55 mg/dL, insulin ≥17 μU/mL, C peptide ≥3.0 ng/mL, and insulin to glucose ratio >0.3 were associated with Roux-en-Y gastric bypass hyperinsulinemic hypoglycemia. Five of 6 patients improved on therapy consisting of dietary modification plus either calcium channel blockade, acarbose, or both. Two patients have remained on therapy for 12 to 15 months. The nonresponder was atypical and had had hypoglycemic events for several decades. Three treated patients were subsequently observed to have undergone partial or complete remission from hypoglycemic episodes after 2 to 37 months of therapy. None of the 6 have undergone pancreatectomy, and none have evidence of insulinoma. Invasive diagnostic procedures were of limited utility. CONCLUSION In a subset of patients with post-Roux-en-Y gastric bypass hyperinsulinemic hypoglycemia, medical management can be efficacious and an alternative to partial pancreatectomy. In some cases, the disorder remits spontaneously.
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Affiliation(s)
- John P Mordes
- Department of Medicine, Division of Endocrinology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Laura C Alonso
- Division of Diabetes, University of Massachusetts Medical School, Worcester, Massachusetts
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Hawkes CP, Adzick NS, Palladino AA, De León DD. Late Presentation of Fulminant Necrotizing Enterocolitis in a Child with Hyperinsulinism on Octreotide Therapy. Horm Res Paediatr 2016; 86:131-136. [PMID: 26867223 PMCID: PMC4982848 DOI: 10.1159/000443959] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/12/2016] [Indexed: 12/12/2022] Open
Abstract
Congenital hyperinsulinism (HI) is the most common cause of persistent hypoglycemia in infants and children. In cases of diazoxide-unresponsive HI, alternative medical and surgical approaches may be required to reduce the risk of hypoglycemia. Octreotide, a somatostatin analog, often has a role in the management of these children, but a dose-dependent reduction in splanchnic blood flow is a recognized complication. Necrotizing enterocolitis (NEC) has been reported within the first few weeks of initiating predominantly high doses of octreotide. We describe the case of an infant with Beckwith-Wiedemann syndrome and diazoxide-unresponsive HI, who had persistent hypoglycemia after two pancreatectomy surgeries. She developed NEC 2 months after beginning octreotide therapy at a relatively low dose of 8 µg/kg/day. This complication has occurred later, and at a lower dose, than has previously been described. We review the case and identify the known and suspected multifactorial risk factors for NEC that may contribute to the development of this complication in patients with HI.
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Affiliation(s)
- Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N Scott Adzick
- Division Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew A Palladino
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Diva D De León
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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18
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Nessa A, Rahman SA, Hussain K. Molecular mechanisms of congenital hyperinsulinism and prospective therapeutic targets. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1064819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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19
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Khawash P, Hussain K, Flanagan SE, Chatterjee S, Basak D. Nifedipine in Congenital Hyperinsulinism - A Case Report. J Clin Res Pediatr Endocrinol 2015; 7:151-4. [PMID: 26316440 PMCID: PMC4563189 DOI: 10.4274/jcrpe.1978] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Congenital hyperinsulinism (CHI) is the commonest cause of persistent hypoglycemia in neonates. Diazoxide is the first-line drug in its treatment, but the more severe cases are usually diazoxide-resistant. Recessive ABCC8 and KCNJ11 mutations are responsible for most (82%) of the severe diazoxide-unresponsive CHI. Oral nifedipine has been effective in isolated cases of CHI. Successful treatment of diazoxide-unresponsive CHI with a combination of octreotide and nifedipine has been reported in a single isolated case so far. We report here a case of diazoxide-resistant CHI due to homozygous ABCC8 nonsense mutation. In this case, hypoglycaemia uncontrolled by pancreatectomy and octreotide alone showed a good response to a combination of nifedipine and octreotide. Octreotide was tapered off by one year age and thereafter the child is euglycaemic on oral nifedipine alone. Continuous glucose monitoring sensor was used as an aid to monitor glycaemic control and was found to be a safe and reliable option reducing the number of needle-pricks in small children.
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Affiliation(s)
- Papiya Khawash
- Park Clinic, Clinic of Paediatrics and Neonatology, Kolkata, India Phone: +91 9831135350 E-mail:
| | - Khalid Hussain
- Institute of Child Health, University College, Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, London, UK
| | - Sarah E. Flanagan
- University of Exeter Faculty of Medicine, Institute Biomedical and Clinical Science, Molecular Genetics, Exeter, UK
| | - Sudip Chatterjee
- Park Clinic, Clinic of Paediatrics and Neonatology, Kolkata, India
| | - Dhananjoy Basak
- Park Clinic, Clinic of Paediatrics and Neonatology, Kolkata, India
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20
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Roženková K, Güemes M, Shah P, Hussain K. The Diagnosis and Management of Hyperinsulinaemic Hypoglycaemia. J Clin Res Pediatr Endocrinol 2015; 7:86-97. [PMID: 26316429 PMCID: PMC4563192 DOI: 10.4274/jcrpe.1891] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Insulin secretion from pancreatic β-cells is tightly regulated to keep fasting blood glucose concentrations within the normal range (3.5-5.5 mmol/L). Hyperinsulinaemic hypoglycaemia (HH) is a heterozygous condition in which insulin secretion becomes unregulated and its production persists despite low blood glucose levels. It is the most common cause of severe and persistent hypoglycaemia in neonates and children. The most severe and permanent forms are due to congenital hyperinsulinism (CHI). Recent advances in genetics have linked CHI to mutations in 9 genes that play a key role in regulating insulin secretion (ABCC8, KCNJ11, GLUD1, GCK, HADH, SLC16A1, UCP2, HNF4A and HNF1A). Histologically, CHI can be divided into 3 types; diffuse, focal and atypical. Given the biochemical nature of HH (non-ketotic), a delay in the diagnosis and management can result in irreversible brain damage. Therefore, it is essential to diagnose and treat HH promptly. Advances in molecular genetics, imaging methods (18F-DOPA PET-CT), medical therapy and surgical approach (laparoscopic surgery) have completely changed the management and improved the outcome of these children. This review provides an overview of the genetic and molecular mechanisms leading to development of HH in children. The article summarizes the current diagnostic methods and management strategies for the different types of CHI.
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Affiliation(s)
| | | | | | - Khalid Hussain
- Great Ormond Street Hospital for Children, UCL Institute of Child Health, Genetics and Epigenetics in Health and Disease, Genetics and Genomic Medicine Programme, London, UK Phone: +44 2079052128 E-mail:
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21
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Abstract
While hypoglycemia occurs commonly among neonates, treatment can be challenging if hypoglycemia persists beyond the first few days of life. This review discusses the available treatment options for both transient and persistent neonatal hypoglycemia. These treatment options include dextrose infusions, glucagon, glucocorticoids, diazoxide, octreotide, and nifedipine. A stepwise, practical approach to the management of these patients is offered.
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Affiliation(s)
- Courtney B Sweet
- Department of Pharmaceutical Services, West Virginia University Hospitals, Morgantown, West Virginia
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22
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Durmaz E, Flanagan SE, Parlak M, Ellard S, Akcurin S, Bircan İ. A combination of nifedipine and octreotide treatment in an hyperinsulinemic hypoglycemic infant. J Clin Res Pediatr Endocrinol 2014; 6:119-21. [PMID: 24932607 PMCID: PMC4141574 DOI: 10.4274/jcrpe.1230] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Hyperinsulinemic hypoglycemia (HH) is the commonest cause of persistent hypoglycemia in the neonatal and infancy periods. Mutations in the ABCC8 and KCNJ11 genes, which encode subunits of the ATP-sensitive potassium channel in the pancreatic beta cell, are identified in approximately 50% of these patients. The first-line drug in the treatment of HH is diazoxide. Octreotide and glucagon can be used in patients who show no response to diazoxide. Nifedipine, a calcium-channel blocker, has been shown to be an effective treatment in a small number of patients with diazoxide-unresponsive HH. We report a HH patient with a homozygous ABCC8 mutation (p.W1339X) who underwent a near-total pancreatectomy at 2 months of age due to a lack of response to diazoxide and octreotide treatment. Severe hypoglycemic attacks continued following surgery, while the patient was being treated with octreotide. These attacks resolved when nifedipine was introduced. Whilst our patient responded well to nifedipine, the dosage could not be increased to 0.75 mg/kg/day due to development of hypotension, a reported side effect of this drug. Currently, our patient, now aged 4 years, is receiving a combination of nifedipine and octreotide treatment. He is under good control and shows no side effects. In conclusion, nifedipine treatment can be started in patients with HH who show a poor response to diazoxide and octreotide treatment.
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Affiliation(s)
- Erdem Durmaz
- Mersin State Hospital, Department of Pediatric Endocrinology, Mersin, Turkey. E-mail:
| | - Sarah E. Flanagan
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Mesut Parlak
- Antalya Training and Research Hospital, Department of Pediatric Endocrinology Clinic, Antalya, Turkey
| | - Sian Ellard
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Sema Akcurin
- Akdeniz University School of Medicine, Department of Pediatrics, Pediatric Endocrinology Division, Antalya, Turkey
| | - İffet Bircan
- Akdeniz University School of Medicine, Department of Pediatrics, Pediatric Endocrinology Division, Antalya, Turkey
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23
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Abstract
Persistent hyperinsulinaemic hypoglycaemia in infancy (PHHI) is a heterogeneous condition characterised by unregulated insulin secretion in response to a low blood glucose level. It is the most common cause of severe and persistent hypoglycaemia in neonates. It is extremely important to recognise this condition early and institute appropriate management to prevent significant brain injury leading to complications like epilepsy, cerebral palsy and neurological impairment. Histologically, PHHI is divided mainly into three types-diffuse, focal and atypical disease. Fluorine-18-l-3,4-dihydroxyphenylalanine positron emission tomography (18F-DOPA-PET/CT) scan allows differentiation between diffuse and focal diseases. The diffuse form is inherited in an autosomal recessive (or dominant) manner whereas the focal form is sporadic in inheritance and is localised to a small region of the pancreas. The molecular basis of PHHI involves defects in key genes (ABCC8, KCNJ11, GCK, SLC16A1, HADH, UCP2, HNF4A and GLUD1) that regulate insulin secretion. Focal lesions are cured by lesionectomy whereas diffuse disease (unresponsive to medical therapy) will require a near-total pancreatectomy with a risk of developing diabetes mellitus and pancreatic exocrine insufficiency. Open surgery is the traditional approach to pancreatic resection. However, recent advances in laparoscopic surgery have led to laparoscopic near-total pancreatectomy for diffuse lesions and laparoscopic distal pancreatectomy for focal lesions distal to the head of the pancreas.
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Affiliation(s)
- Pratik Shah
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London
| | - Huseyin Demirbilek
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London
| | - Khalid Hussain
- Department of Developmental Endocrinology Research Group, Clinical and Molecular Genetics Unit, Institute of Child Health, University College London; Department of Paediatric Endocrinology, Great Ormond Street Hospital for Children, London.
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24
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Patel K, Shikare M, Chavan D, Sawant P. Anesthetists approach in a neonate with nesidioblastoma undergoing pancreatectomy. J Anaesthesiol Clin Pharmacol 2013; 29:384-6. [PMID: 24106367 PMCID: PMC3788241 DOI: 10.4103/0970-9185.117108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is rare, but an important cause of hypoglycemia in infants, associated with a number of structural abnormalities of the endocrine pancreas is collectively termed as “Islet cell dysmaturation syndrome.” We present the anesthetic management in a clinically diagnosed case of PHHI in a 22 days old full term child, undergoing Subtotal Pancreatectomy. We have discussed the challenges faced in the intra-operative period in managing this neonate for pancreatic resection surgery with focus on intra-operative management of blood glucose levels.
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Affiliation(s)
- Kiran Patel
- Department of Pediatric Anesthesiology, B. J. Wadia Hospital, Parel, Mumbai, India
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25
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Quan Y, Barszczyk A, Feng ZP, Sun HS. Current understanding of K ATP channels in neonatal diseases: focus on insulin secretion disorders. Acta Pharmacol Sin 2011; 32:765-80. [PMID: 21602835 PMCID: PMC4009965 DOI: 10.1038/aps.2011.57] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2011] [Accepted: 04/13/2011] [Indexed: 12/25/2022] Open
Abstract
ATP-sensitive potassium (K(ATP)) channels are cell metabolic sensors that couple cell metabolic status to electric activity, thus regulating many cellular functions. In pancreatic beta cells, K(ATP) channels modulate insulin secretion in response to fluctuations in plasma glucose level, and play an important role in glucose homeostasis. Recent studies show that gain-of-function and loss-of-function mutations in K(ATP) channel subunits cause neonatal diabetes mellitus and congenital hyperinsulinism respectively. These findings lead to significant changes in the diagnosis and treatment for neonatal insulin secretion disorders. This review describes the physiological and pathophysiological functions of K(ATP) channels in glucose homeostasis, their specific roles in neonatal diabetes mellitus and congenital hyperinsulinism, as well as future perspectives of K(ATP) channels in neonatal diseases.
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Affiliation(s)
- Yi Quan
- Departments of Physiology, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8
| | - Andrew Barszczyk
- Departments of Physiology, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8
| | - Zhong-ping Feng
- Departments of Physiology, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8
| | - Hong-shuo Sun
- Departments of Physiology, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8
- Departments of Surgery, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8
- Departments of Pharmacology, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8
- Institute of Medical Science, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada, M5S 1A8
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Marquard J, Palladino AA, Stanley CA, Mayatepek E, Meissner T. Rare forms of congenital hyperinsulinism. Semin Pediatr Surg 2011; 20:38-44. [PMID: 21186003 DOI: 10.1053/j.sempedsurg.2010.10.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Rare forms of congenital hyperinsulinism (CHI) are caused by mutations in GLUD1 (encoding glutamate dehydrogenase), GCK (encoding glucokinase), HADH (encoding for L-3-hydroxyacyl-CoA dehydrogenase), SLC16A1 (encoding the monocarboxylat transporter 1), HNF4A (encoding hepatocyte nuclear factor 4α) or UCP2 (encoding mitochondrial uncoupling protein 2). The clinical presentation is very heterogeneous in regards to age of onset, severity, and manner of symptoms, as well as the response to medical treatment. Special individual characteristics have to be accounted in diagnosis and treatment. Diazoxide is the first-line drug for the rare forms of CHI for long-term treatment but is not entirely effective in some of these rarer defects (GCK, MCT1). The use of diazoxide is often limited by side effects and the use of octreotide as second-line drug has to be considered. A near-total pancreatectomy is only reserved for patients with diffuse disease and resistance to medical treatment as a last resort. Patients with CHI should be managed by centers with a highly experienced team in diagnostic work-up and treatment of this disease.
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Affiliation(s)
- Jan Marquard
- Department of General Pediatrics, University Children's Hospital Düsseldorf, Germany.
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27
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Guseva N, Phillips D, Mordes JP. Successful treatment of persistent hyperinsulinemic hypoglycemia with nifedipine in an adult patient. Endocr Pract 2010; 16:107-11. [PMID: 19625246 DOI: 10.4158/ep09110.crr] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To describe the successful treatment of severe noninsulinoma hyperinsulinemic hypoglycemia with use of a calcium channel blocking agent in an adult patient who had previously undergone a gastric bypass surgical procedure. METHODS A 65-year-old woman who had undergone a gastric bypass surgical procedure 26 years earlier was hospitalized because of severe postprandial hypoglycemia. During and after hospitalization, the patient underwent assessment with conventional measurements of glucose, insulin, proinsulin, and C-peptide; toxicologic studies; magnetic resonance imaging studies of the pancreas; and determination of hepatic vein insulin concentrations after selective splanchnic artery calcium infusion. RESULTS Metabolic variables were consistent with the diagnosis of hyperinsulinemic hypoglycemia. Magnetic resonance imaging revealed the presence of a side branch intraductal papillary mucinous tumor that had been stable for more than 1 year. The results of the calcium-stimulated insulin release study were consistent with nonlocalized hypersecretion of insulin. A trial of frequent small feedings failed to prevent hypoglycemia. On the basis of reports of successful treatment of childhood nesidioblastosis, the patient was then prescribed nifedipine, 30 mg daily. She has subsequently remained free of symptomatic hypoglycemia for 20 months. CONCLUSION A calcium channel blocking agent may be efficacious and a potential alternative to partial pancreatectomy in cases of noninsulinoma hyperinsulinemic hypoglycemia in adults.
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Affiliation(s)
- Nina Guseva
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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Abstract
Congenital hyperinsulinism is the principle cause of hypoglycemia during infancy but successful treatment is difficult and persistent hypoglycemia carries the risk of neurologic damage. Focal and diffuse abnormalities are the common forms of hyperinsulinism. Identification and localization of focal hyperinsulinism can be cured by partial pancreatectomy. It has been shown that affected pancreatic areas utilize LDOPA in a higher rate than normal pancreatic tissue and, thus, labeling L-DOPA with fluorine-18 (FDOPA) allows functional mapping of hyperinsulinism using PET. This article presents a fundamental overview of the genetics background, pathology, management, and the role of FDOPA-PET imaging in hyperinsulinism.
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Kapoor RR, James C, Hussain K. Advances in the diagnosis and management of hyperinsulinemic hypoglycemia. ACTA ACUST UNITED AC 2009; 5:101-12. [PMID: 19165222 DOI: 10.1038/ncpendmet1046] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 11/12/2008] [Indexed: 12/16/2022]
Abstract
Hyperinsulinemic hypoglycemia (HH) is a consequence of unregulated insulin secretion by pancreatic beta-cells and is a major cause of hypoglycemic brain injury and mental retardation. Congenital HH is caused by mutations in genes involved in regulation of insulin secretion, seven of which have been identified (ABCC8, KCNJ11, GLUD1, CGK, HADH, SLC16A1 and HNF4A). Severe forms of congenital HH are caused by mutations in ABCC8 and KCNJ11, which encode the two components of the pancreatic beta-cell ATP-sensitive potassium channel. Mutations in HNF4A, GLUD1, CGK, and HADH lead to transient or persistent HH, whereas mutations in SLC16A1 cause exercise-induced HH. Rapid genetic analysis combined with an understanding of the histological features (focal or diffuse disease) of congenital HH and the introduction of (18)F-L-3,4-dihydroxyphenylalanine PET-CT to guide laparoscopic surgery have totally transformed the clinical approach to this complex disease. Adult-onset HH is mostly caused by an insulinoma; however, it has also been reported to present as postprandial HH in patients with noninsulinoma pancreatogenous hypoglycemia syndrome, in those who have undergone gastric-bypass surgery for morbid obesity, and in those with mutations in the insulin-receptor gene.
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Affiliation(s)
- Ritika R Kapoor
- Institute of Child Health, University College London and Great Ormond Street Hospital for Children National Health Services Trust, London, UK
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Dunne MJ, Cosgrove KE, Shepherd RM, Aynsley-Green A, Lindley KJ. Hyperinsulinism in Infancy: From Basic Science to Clinical Disease. Physiol Rev 2004; 84:239-75. [PMID: 14715916 DOI: 10.1152/physrev.00022.2003] [Citation(s) in RCA: 185] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Dunne, Mark J., Karen E. Cosgrove, Ruth M. Shepherd, Albert Aynsley-Green, and Keith J. Lindley. Hyperinsulinism in Infancy: From Basic Science to Clinical Disease. Physiol Rev 84: 239–275, 2004; 10.1152/physrev.00022.2003.—Ion channelopathies have now been described in many well-characterized cell types including neurons, myocytes, epithelial cells, and endocrine cells. However, in only a few cases has the relationship between altered ion channel function, cell biology, and clinical disease been defined. Hyperinsulinism in infancy (HI) is a rare, potentially lethal condition of the newborn and early childhood. The causes of HI are varied and numerous, but in almost all cases they share a common target protein, the ATP-sensitive K+channel. From gene defects in ion channel subunits to defects in β-cell metabolism and anaplerosis, this review describes the relationship between pathogenesis and clinical medicine. Until recently, HI was generally considered an orphan disease, but as parallel defects in ion channels, enzymes, and metabolic pathways also give rise to diabetes and impaired insulin release, the HI paradigm has wider implications for more common disorders of the endocrine pancreas and the molecular physiology of ion transport.
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Affiliation(s)
- Mark J Dunne
- Research Division of Physiology and Pharmacology, The School of Biological Sciences, University of Manchester, Manchester, United Kingdom.
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MacDonald PE, Wheeler MB. Voltage-dependent K(+) channels in pancreatic beta cells: role, regulation and potential as therapeutic targets. Diabetologia 2003; 46:1046-62. [PMID: 12830383 DOI: 10.1007/s00125-003-1159-8] [Citation(s) in RCA: 182] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2003] [Revised: 05/23/2003] [Indexed: 01/11/2023]
Abstract
Insulin secretion from pancreatic islet beta cells is acutely regulated by a complex interplay of metabolic and electrogenic events. The electrogenic mechanism regulating insulin secretion from beta cells is commonly referred to as the ATP-sensitive K(+) (K(ATP)) channel dependent pathway. Briefly, an increase in ATP and, perhaps more importantly, a decrease in ADP stimulated by glucose metabolism depolarises the beta cell by closing K(ATP) channels. Membrane depolarisation results in the opening of voltage-dependent Ca(2+) channels, and influx of Ca(2+) is the main trigger for insulin secretion. Repolarisation of pancreatic beta cell action potential is mediated by the activation of voltage-dependent K(+) (Kv) channels. Various Kv channel homologues have been detected in insulin secreting cells, and recent studies have shown a role for specific Kv channels as modulators of insulin secretion. Here we review the evidence supporting a role for Kv channels in the regulation of insulin secretion and discuss the potential and the limitations for beta-cell Kv channels as therapeutic targets. Furthermore, we review recent investigations of mechanisms regulating Kv channels in beta cells, which suggest that Kv channels are active participants in the regulation of beta-cell electrical activity and insulin secretion.
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Affiliation(s)
- P E MacDonald
- Department of Physiology, University of Toronto, Toronto, Ontario M5S 1A8, Canada.
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Abstract
Hyperinsulinism (HI) is the commonest cause of persistent or recurrent hypoglycaemia in childhood. HI is genetically and phenotypically diverse. Key management issues involve early diagnosis by insuring that appropriate investigations are undertaken at the point of hypoglycaemia, prevention of recurrent hypoglycaemia and clinical, biochemical and genetic characterisation of the HI syndrome. Children with persistent diazoxide resistant HI require investigation at specialist centres to differentiate those with a generalised disorder of the pancreas (diffuse HI; di-HI) from those with localised abnormalities within the pancreas (focal HI; fo-HI). Fo-HI may be managed by selective pancreatic resection of the focal abnormality. Di-HI is only managed by surgery if combination drug therapies are unable to prevent hypoglycaemia. Pancreatic beta-cell dysfunction persists following subtotal pancreatectomy of di-HI.
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Affiliation(s)
- Keith J Lindley
- The Institute of Child Health, University College London, London, UK.
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Shanbag P, Pathak A, Vaidya M, Shahid SK. Persistent hyperinsulinemic hypoglycemia of infancy--successful therapy with nifedipine. Indian J Pediatr 2002; 69:271-2. [PMID: 12003307 DOI: 10.1007/bf02734240] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Recent studies have demonstrated a role for calcium channel blocking agents in the treatment of persistent hyperinsulinemic hypoglycemia of infancy. We report a 30 day old infant with PHHI whom we successfully treated with oral nifedipine alone.
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Affiliation(s)
- Preeti Shanbag
- Pediatric Intensive Care Unit, Lokmanya Tilak Municipal Medical College & General Hospital, Sion, Mumbai, India.
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