Title: Genetics of Diabetes
1Genetics of Diabetes
- Jan Dorman, PhD
- University of Pittsburgh
- School of Nursing
- jsd_at_pitt.edu
2Type 1 Diabetes (T1D)
3Type 1 Diabetes
- Caused by the destruction of the pancreatic beta
cells - Insulin is no longer produced
- Leads to hyperglycemia, ketoacidosis and
potentially death if not treated with insulin - Treatment goals for T1D
- Maintaining near normal levels of blood glucose
- Avoidance of long-term complications
4Type 1 Diabetes
- 2nd most common chronic childhood disease
- Peak age at onset is around puberty
- But T1D can occur at any age
- Incidence is increasing worldwide by 3 per year
- Related to increase in T2D?
5T1D Incidence Worldwide
6Importance of Environmental Risk Factors in T1D
- Seasonality at diagnosis
- Migrants assume risk of host country
- Risk factors from case-control studies
- Infant/childhood diet
- Viruses exposures as early as in utero
- Hormones
- Stress
- Improved hygiene
- Vitamin D
7Importance of Genetic Risk Factors in T1D
- Concordance in identical twins greater in MZ
versus DZ twins - 15-fold increased risk for 1st degree relatives
- Risk is 6 through age 30 years
- Risk increases in presence of susceptibility
genes
8MHC Region Chromosome 6p21
9Predisposition to T1D is Better Determined by
Haplotypes
- DRB1-DQB1 haplotypes more accurately determine
T1D risk - Testing for both genes is more expensive
- Most screening is based only on DQA1-DQB1
- High risk T1D haplotypes
- DQA10501-DQB10201
- DQA10301-DQB10302
10Relative Increase in T1D Risk by Number of High
Risk Haplotypes
11Absolute T1D Risk (to age 30) by Number of High
Risk Haplotypes
12Absolute T1D Risk for Siblings of Affected
Individuals
13Genome Screens for T1D
14IDDM2
- Insulin (INS) gene
- Chromosome 11p15, OMIM 176730
- Variable number of tandem repeats (VNTR)
- Class I 26-63 repeats
- Class II 80 repeats
- Class III 141-209 repeats
- Relative increase in risk 2-fold with two class
I alleles (compared to 0 class I alleles) - Class I is associated with lower mRNA in the
thymus may reduce tolerance to insulin and its
precursors
15IDDM12
- Cytotoxic T Lymphocyte Associated-4 (CTLA-4)
- Chromosome 2q33, OMIM 123890
- ICOS and CD28 flank
- Encodes a T cell receptor that plays are role in
T cell apoptosis - A49G polymorphism (Thr17Ala)
- Relative increase in risk 1.2
- Dysfunction of CTLA-4 is consistent with
development of T1D
16PTPN22
- Lymphoid specific tyrosine phosphatase (LYP)
- Chromosome 1p13, OMIM 600716
- Encodes a LPY that is important in negative
T-cell activation and development - C858T polymorphism (Arg620Trp)
- Relative increase in risk 1.8
- May alter binding of LYP to cytoplasmic tyrosine
kinase, which regulates the T-cell receptor
signaling kinases
17Intervention Trials for T1D
- Study Intervention Target /Screen
- TRIGR Avoid CM FDR / genetic
- DIPP Insulin (N) GP / genetic
- TrialNet Immunosuppressive FDR / antibodies
- agents and genetic
-
- CM cows milk, N nasal,
- FDR first degree relatives, GP general
population
18Natural History Studies for T1D
- Conducted in the general population
- DAISY - Colorado
- PANDA - Florida
- TEDDY US and Europe
- Based on newborn genetic screening
- Concerns about proper informed consent
- Parents are notified of the results by mail
- General population at high risk (5-8)
recruited for follow-up - 50 of children who will develop T1D not eligible
19Genetics and Prevention of T1D
- Type 1 diabetes cannot be prevented
- Ethical concerns regarding genetic testing for
T1D, especially in children - Education programs are need for parents who
consent to have their children involved in such
studies because risk estimation is - Dependent on genes/autoantibodies used for
assessment - Is not sensitive or specific
20Type 2 Diabetes (T2D)
21Type 2 Diabetes
- Is group of genetically heterogeneous metabolic
disorders that cause glucose intolerance - Involves impaired insulin secretion and insulin
action - 90 of individuals with diabetes have T2D
- Considerations
- May be treated with diet / oral medications /
physical activity - T2D individuals may be asymptomatic for many
years - Associated with long-term complications
- Polygenic and multifactorial
- Caused by multiple genes that may interact
- Caused by genetic and environmental risk factors
22 Blood glucose
levels
Genetic effects
Insulin secretion and Insulin resistance
Environmental effects
Fatty acid
levels
From McIntyre and Walker, 2002
23Thrifty Genotype
- Had a selective advantage
- In primitive times, individuals who were
metabolically thrifty were - Able to store a high proportion of energy as fat
when food was plentiful - More likely to survive times of famine
- In recent years, most populations have
- A continuous supply of calorie-dense processed
foods - Reduced physical activity
- These changes likely explain the rise in T2D
worldwide
24Revised Classification Criteria for T2D
- Fasting plasma glucose
- 7.0 mmol/L
- 126 mg/dl
- Random blood glucose
- 11.1 mmol/L
- 200 mg/dl
25T2D Prevalence Worldwide
26Estimated Number of Adults with Diabetes
Developing Countries
www.who.int/diabetes/actionnow/en/diabprev.pdf
27Estimated Number of Adults with Diabetes
Developed Countries
www.who.int/diabetes/actionnow/en/diabprev.pdf
28Increase in T2D in Children
- Most T2D children were females from minority
populations - Mean age at onset was around puberty
- Many had a family history of T2D
29Environmental Risk Factors in T2D
- Obesity
- Increases risk of developing T2D
- Defined as
- 120 of ideal body weight
- Body mass index (BMI) 30 k / m2
- Likely related to the increase in T2D
- 80 newly diagnosed cases due to obesity
- Higher association with abdominal or central
obesity - Assessed by measuring the waist-to- hip ratio
30Environmental Risk Factors in T2D
- Physical Activity
- Increases risk of developing T2D
- Exercise
- Controls weight
- Improves glucose and lipid metabolism
- Is inversely related to body mass index
- Lifestyle interventions decreased risk of
progression of impaired glucose tolerance to T2D
by 60
31Genetics and T2D
- Individuals with a positive family history are
about 2-6 times more likely to develop T2D than
those with a negative family history - Risk 40 if T2D parent 80 if 2 T2D parents
- Higher concordance for MZ versus DZ twins
- Has been difficult to find genes for T2D
- Late age at onset
- Polygenic inheritance
- Multifactorial inheritance
32Finding Genes for T2D
- Candidates selected because they are involved in
- Pancreatic beta cell function
- Insulin action / glucose metabolism
- Energy intake / expenditure
- Lipid metabolism
- Genome wide screens
- Nothing is assumed about disease etiology
- Genome wide association studies
- Current approach based on thousands of cases and
controls
33Challenges in Finding Genes
- Inadequate sample sizes
- Multiplex families
- Cases and controls
- Difficult to define the phenotype
- Reduced penetrance
- Influence of environmental factors
- Gene-gene interactions
- Variable age at onset
- Failure to replicate findings
- Genes identified have small effects
34CAPN10 NIDDM1
- Chromosome 2q37.3 (OMIM 601283)
- Encodes an intracellular calcium-dependent
cytoplasmic protease that is ubiquitously
expressed - May modulate activity of enzymes and/or apoptosis
- Likely involves insulin secretion and resistance
- Stronger influence in Mexican Americans than
other ethnic groups - Responsible for 40 if familial clustering
- Genetic variant A43G, Thr50Ala, Phe200Thr
- Estimated relative risk 2
35PPAR?
- Peroxisome proliferator-activated receptor-?
(chromosome 3p25, OMIM 601487) - Transcription factors that play an important role
in adipocyte differentiation and function - Is associated with decreased insulin sensitivity
- Target for hypoglycemic drugs -thiazolidinediones
- Genetic variant Pro12Ala, Pro is risk allele
(common) - Estimated relative risk 1 - 3
- Variant is common
- May be responsible for 25 of T2D cases
36ABCC8 and KCNJ11
- ATP-binding cassette, subfamily C member 8
(chromosome 11p15.1, OMIM 600509) - Potassium channel, inwardly rectifying, subfamily
J, member 11 (chromosome 11p15.1, OMIM 600937) - ABCC8 encodes the sulfonylurea receptor (drug
target ) - Is coupled to the Kir6.2 subunit (encoded by
KCNJ11 4.5 kb apart near INS ) - Part of the ATP-sensitive potassium channel
- Involved in regulating insulin and glucagon
- Mutations affect channels activity and insulin
secretion - Site of action of sulfonylureal drugs
- Genetic variants Ser1369Ala Glu23Lys,
respectively - Estimated relative risk 2 4
37TCF7L2
- Transcription factor 7-like 2 (chromosome 10q25,
OMIM 602228) - Related to impaired insulin release of
glucagon-like peptide-1 (islet secretagogue),
reduced ß-cell mass or ß-cell dysfunction - Stronger among lean versus obese T2D
- 10 of individuals are homozygous have 2-fold
increase in risk relative to those with no copy
of the variant - Responsive to sulfunynlureals not metformin
- Genetic variant re7901695 and others in LD
- Estimated relative risk 1.4
38GWAS New Loci Identified
- FTO chr 16q12
- Fat mass and obesity associated gene
- Governs energy balance gene expression is
regulated by feeding and fasting - Estimated relative risk 1.23
- HHEX/IDE chr 10q23-24 near TCF7L2
- HHEX - Haematopoietically expressed homeobox
- Transcription factor in liver cells
- IDE - Insulin degrading enzyme
- Has affinity for insulin inhibits IDE-mediated
degradation of other substances - Estimated relative risk 1.14
39GWAS New Loci Identified
- CDKAL1 chr 6p22
- Cyclin-dependent kinase regulatory subunit
associated protein 1-like 1 - Likely plays role in CDK5 inhibition and
decreased insulin secretion - Estimated relative risk 1.12
- SLC30A8 chr 8q24
- Solute carrier family 30 zinc transporter
- May be major autoantigen for T1D
- Estimated relative risk 1.12
40GWAS New Loci Identified
- IGF2BP2 chr 3q28
- Insulin-like growth factor 2 mRNA binding protein
2 - Regulates IGF2 translation stimulates insulin
action - Estimated relative risk 1.17
- CDKN2A/B chr 9p21
- Clycin dependent kinase inhibitor 2A
- Plays role in pancreatic development and islet
proliferation - Estimated relative risk 1.2
41T2D Genes are Drug Targets
- PPAR?, ABCC8 and KCNJ11 are the targets of drugs
used routinely in the treatment of T2D - Pharmacogenetic implications
- Response to oral agents may be related to ones
genotype - Genetic testing may
- Identify individuals at high risk for T2D
- Guide treatment regimens for T2D
- Individualize therapy
42Genetics and Prevention of T2D
- T2D is preventable
- Maintaining age-appropriate body weight
- Physical activity
- New genes will provide insight to etiology
- Public health messages may have a greater
influence on genetically susceptible - Will genetic testing prevent T2D?
- Unclear whether knowledge of ones genetic risk
will lead to behavior modifications
43Genetics and Prevention of T2D
- Challenges include
- Predictive values of most test is low
- How to communicate risk information?
- Health care professionals may not be able to
interpret genetic tests - Genetic testing may lead to distress, etc.
- Insurance and employment discrimination
- Confidentiality and stigmatization
- Direct to consumer marketing for genetic testing
44Maturity Onset Diabetes of the Young (MODY)
45MODY
- Account for 5 of type 2 diabetes
- Single gene defects
- Autosomal dominant inheritance
- Multiple generations affected
- Early age at onset (
- Characterized by the absence of obesity, no
ketosis and no evidence of beta cell autoimmunity - Hyperglycemia often corrected by diet
46MODY Genes
47MODY1 is HNF4A (hepatocyte nuclear factor
4-alpha) on 20q12-q13.1
- Transcription factor
- Expressed in the liver, kidney, intestine and
pancreatic islet cells - Has been associated with T2D
- Controls genes involved in glucose, cholesterol
and fatty acid metabolism - Controls transcription of HNF1A (MODY3)
- Several mutations/splicing defects identified
- Account for 5 of all MODY cases
48MODY2 is GCK (glucokinase) on 7p15-p13
- Only MODY gene that is not a transcription factor
- Required for glucose metabolism and insulin
secretion acts as a glucose sensor - MODY2 is generally a mild form of diabetes
- 200 mutations have been identified
- VNTR, nonsense and missense mutations
- Account for 15 of all MODY cases
49MODY3 is HNF1A (hepatocyte nuclear factor
1-alpha) on 12q24.2
- Regulates expression of insulin and other genes
involved in glucose transport / metabolism - Influences expression of HNF4A (MODY1)
- Results in a severe insulin secretory defect
- May contribute to abnormal islet cell development
- More than 100 genetic variants have been
identified - Mutations in MODY3 are the most common cause of
MODY - Account for 65 of all MODY cases
- Sensitive to sulphonylureas
50MODY4 is IPF1 (insulin promoter factor-1) on
13q12.1
- Transcription factor that regulates expression of
insulin, somatostatin and other genes - Involved in the development of the pancreas
- In adults, expressed only in pancreatic cells
- Mutations lead to decreased binding activity to
the insulin promoter - Reduced activation of insulin gene in response to
glucose - Genetic variants include frameshift, insertions
and missense mutations - Accounts for a very small proportion of MODY cases
51MODY5 is HNF1B (hepatocyte nuclear factor 1-beta)
on 17cen-q21.3
- Transcription factor required for liver-specific
expression of a variety of genes - Is highly homologous to HNF1A (MODY3)
- Recognizes same binding site as HNF1A
- HNF1A and HNF1B likely interact to regulate gene
expression - Individuals have lower renal threshold to glucose
- Is a rare cause of MODY
52MODY6 is NEUROD1 (neurogenic differentiation
factor 1) on 2q32
- Is a transcription factor involved in the
differentiation of neurons - Regulates insulin gene expression by binding to a
critical motif on the insulin promoter - Few genetic variants identified
- Missense and nonsense mutations
- Account for 1 of all MODY cases
53Summary of MODY Genetics
- All MODY genes are expressed in the pancreas, and
play a role in - The metabolism of glucose
- The regulation of insulin or other genes involved
in glucose transport - The development of the fetal pancreas
- MODY phenotype depends on the MODY genotype (on
next slide) - Knowing the genotype is important to determine
treatment
54MODY Phenotpes
D Diet, O Oral agents, I Insulin