소아 제 2형 당뇨병 환아에서 Maturity Onset Diabetes of the Young(MODY) 3의 유병률에 관한 연구 = The Prevalence of Maturity Onset Diabetes of the Young(MODY) 3 in Children with Type 2 Diabetes Mellitus

다국어 초록 (Multilingual Abstract)

Purpose:Maturity-onset diabetes of the young(MODY) is a subtype of type 2 diabetes defined by autosomal dominant mode of inheritance, onset of diabetes usually before the age of 25 yrs, and a primary defect in the function of the beta cells of the pancreas. MODY3 is known as the most common form and is caused by mutations in hepatocyte nuclear factor(HNF)-1α. We examined the prevalence of MODY3 in children with type 2 diabetes mellitus(DM).
Methods:Children with type 2 DM(N=17) and their family members with type 2 DM(N=5) were enrolled. Inclusion criteria for the children were fasting C-peptide and postprandial C-peptide more than 1.0 ng/mL and 1.5 ng/mL respectively, familial type 2 DM in at least two generations, and body mass index(BMI)(kg/m2) less than 95th percentile. Genomic DNA was extracted from blood samples. We analyzed HNF-1α for mutation by DNA microarray method and direct sequencing.
Results:We found one case with a mutation of the promoter region of HNF-1α(5'-ctaGGCTAGTGGGGTTTTGCGGGGGCAGTGGGTGCAAGG-3') in one child's family member among 22 children and adult subjects with type 2 DM.
Conclusion:Although we found a mutation of HNF-1α in an adult family member with type 2 DM, we did not find this mutation in a child with type 2 DM. The further investigation of MODY in children, including other types, is required.

국문 초록 (Abstract)

목 적 : MODY는 제 2형 당뇨병의 환자 중 25세 이전에 발병하고, 상염색체 우성 유전으로 2대 이상의 가족력이 있고, 췌장 베타 세포의 기능이상을 보이는 질환이다. MODY3는 MODY 중 가장 흔한 형태로 12번 염색체 장완의 돌연변이로 HNF-1α 유전자의 돌연변이에 의해 발생한다. 한국에서는 아직까지 소아환자에서 유전자 변이 검색을 통한 MODY의 진단은 미미한 실정이다. 이에 본 연구에서는 가족력을 가지면서 제 2형 당뇨병으로 진단받은 환아에서 DNA microarray 및 direct sequencing을 통하여, MODY3 유병률에 관하여 알아보았다.방 법 : 세브란스병원 소아과에서 제 2형 당뇨병으로 진단받은 환아들을 대상으로 하여, C-peptide가 공복시 1.0 ng/mL 이상, 식후 1.5 mg/mL 이상이면서, 2세대 이상의 당뇨병의 가족력이 있고, 체질량 지수(kg/m2)가 95 퍼센타일 미만인 환아 17명과 그 가족 중 제 2형 당뇨병으로 진단받은 성인 5명을 대상으로 하였다. 환자 및 가족으로부터 말초혈액을 5 mL를 채취하여 genomic DNA를 추출하였다. DNA microarray를 이용한 DNA칩 검사를 위해 PCR을 통해 DNA를 증폭시키고, Cy3를 첨가하여 라벨화하였으며, 혼성화 과정과 세척, 건조과정을 거쳐 GenePix 4000B 스캐너와 GenePix Prosoftware(Axon Instruments, Union City, CA)를 이용해 자료를 영상화 하였다. Direct DNA sequencing은 ABI bigDye termintor sequencing 키트(Applied Biosystems, Foster City, CA, USA)를 이용하였으며, PCR은 36회로 변성은 96℃에서 10초간, 결합은 50℃에서 5초간, 확장은 60℃에서 4분간 시행하였다. Sequencing 산물은 ABI 3700 DNA analyzer로 분석하였다.결 과 : 대상환아 17명은 남자 6명과 여자 11명이었으며, 진단시 평균 연령은 13.0±1.3세였다. 공복시와 식후 C-peptide 수치(ng/mL)가 각각 2.1±0.9, 3.4±1.5이었으며, 체질량지수는 21±1.8이었다. 22명의 환아 및 가족 중에서 1례에서 DNA 칩을 통해 1개의 돌연변이가 발견되었으며, direct sequencing 결과 HNF-1α 유전자의 프로모터 부위에서 G에서 C로의 치환(5'- ctaGGCTAGTGGGGTTTTGCGGGGGCAGTGGGTGCAAGG- 3')이 발견되었다. 변이가 판명된 환자는 성인으로, 진단 당시 연령은 40세였으며, 진단 당시 체질량지수는 25였으며, 현재 경구 혈당강하제와 인슐린 치료를 병행하고 있다. 환자의 형제들(오빠 2분, 여동생 1분)에게 추가로 유전자 검사를 시행한 결과 여동생에게서 DNA칩을 통해 1개의 돌연변이가 발견되었으며, direct sequencing결과 이미 변이가 밝혀진 가족과 동일한 부위의 HNF-1α의 돌연변이가 발견되었다. 하지만 여동생은 당뇨의 임상증상을 가지고 있지 않았다.

참고문헌 (Reference)

1 "Three new mutations in the hepatocyte nuclear factor-1α gene in Japanese subjects with diabetes mellitus:clinical features and functional characterization" 42 : 621-626, 1999

2 "The bifunctional protein DCoH modulates interactions of the homeodomain transcription factor HNF1 with nucleic acids" 265 : 20-29, 1997

3 "Structure of the gene encoding hepatocyte nuclear factor 1(HNF1)" 20 : 4199-4204, 1992

4 "Scope and heterogenous nature of MODY" 13 : 49-64, 1990

5 "Routine mutation screening of HNF-1α and GCK genes in MODY diagnosis : how effective are the techniques of DHPLC and direct sequencing used in combination?" 44 : 775-778, 2001

6 "Polymorphism of the hepatocyte nuclear factor-1α gene in the early-onset of type 2 diabetes mellitus with a strong family history in Korea" 26 : 328-335, 2002

7 "Mutations in the hepatocyte nuclear factor-4α gene in maturity-onset diabetes of the young(MODY1)" 384 : 458-460, 1996

8 "Mutations in the hepatocyte nuclear factor-1α gene in maturity-onset diabetes of the young(MODY3)" 384 : 455-458, 1996

9 "Mutations in hepatocyte nuclear factor-1α in early- onset type 2 diabetes mellitus in Korea" 23 : 793-802, 1999

10 "Mutations in NEUROD1 are associated with the development of type 2 diabetes mellitus" 23 : 323-328, 1999

11 "Mutation in hepatocyte nuclear factor-1β gene(TCF2)associated with MODY" 17 : 384-385, 1997

12 "Modulation of hepatic gene expression by hepatocyte nuclear factor1" 227 : 109-112, 1997

13 "Maturity-onset diabetes of the young : a model for genetic studies of diabetes mellitus. In : Diabetes mellitus : a fundamental and clinical test" Lippincott Williams& Wilkins 691-705, 2000

14 "LFB1 and LFB3 homeoproteins are sequentially expressed during kidney development" 114 : 469-474, 1992

15 "Hepatocyte nuclear factor1(HNF1) and liver gene expression. In : Liver Gene Expression" Austin : RG Landes 155-181, 1994

16 "Hepatocyte nuclear factor inactivation results in hepatic dysfunction, phenylketonuria and renal Fanconi syndrome" 84 : 575-585, 1996

17 "Hepatocyte nuclear factor 1α is expressed in a hamster insulinoma line and transactivates the rat insulin I gene" 89 : 7300-7304, 1992

18 "HNF-1α a member of a novel class of dimerizing homeodomain proteins" 266 : 677-680, 1991

19 "HNF-1α a homeoprotein member of the hepatic transcription regulatory network" 14 : 579-587, 1992

20 "Genetics of non-insulin- dependent(type II)diabetes mellitus" 47 : 509-531, 1996

21 "Familial hyperglycemia due to mutations in glucokinase:definition of a subtype of diabetes mellitus" 328 : 697-702, 1993

22 "Epidemiology and genetics of diabetes mellitus. In : Joslin's Diabetes Mellitus" Lea and Febiger 201-221, 1998

23 "Early-onset type II diabetes mellitus(MODY4)linked to IPF1" 17 : 138-139, 1997

24 "Characteristics of childhood diabetes" 38 : 1116-1123, 1995

25 "Big dye terminator cycle sequencing chemistry:accuracy of the dilution process and application for screening mutations in the TCF1 and GCK genes" 15 : 201-203, 2000

26 "Beta cell genes and diabetes:Quantitative and qualitative differences in the pathophysiology of hepatic nuclear factor-1α and glucokinase mutations" 50 (50): 101-107, 2001

27 "An automated fluorescent single-strane conformation polymorphism technique for screening mutations in the hepatocyte nuclear factor-1α gene" 46 : 2108-2109, 1997

28 "APOU-A related region dictates DNA binding specificity of LFB1/HNF1 by orienting the two XL-homeodomains in the dimer" 11 : 4119-4129, 1992

29 "A gene for maturity onset diabetes of the young(MODY)maps to chromosome 12q" 9 : 418-423, 1995

30 "A difference between the inheritance of classical juvenile-onset and maturity-onset type diabetes of young people" 24 : 44-53, 1975