Diabetes 53:2992-2997, 2004 © 2004 by the American Diabetes Association, Inc.
Variation in NCB5ORStudies of Relationships to Type 2 Diabetes, Maturity-Onset Diabetes of the Young, and Gestational Diabetes Mellitus
1 Steno Diabetes Center, Gentofte, Denmark
Recent data show that homozygous Ncb5or/ knock-out mice present with an early-onset nonautoimmune diabetes phenotype. Furthermore, genome-wide scans have reported linkage to the chromosome 6q14.2 region close to the human NCB5OR. We therefore considered NCB5OR to be a biological and positional candidate gene and examined the coding region of NCB5OR in 120 type 2 diabetic patients and 63 patients with maturity-onset diabetes of the young using denaturing high-performance liquid chromatography. We identified a total of 22 novel nucleotide variants. Three variants [IVS5+7del(CT), Gln187Arg, and His223Arg] were genotyped in a case-control design comprising 1,246 subjects (717 type 2 diabetic patients and 529 subjects with normal glucose tolerance). In addition, four rare variants were investigated for cosegregation with diabetes in multiplex type 2 diabetic families. The IVS5+7del(CT) variant was associated with common late-onset type 2 diabetes; however, we failed to relate this variant to any diabetes-related quantitative traits among the 529 control subjects. Thus, variation in the coding region of NCB5OR is not a major contributor in the pathogenesis of nonautoimmune diabetes.
Type 2 diabetes is a common metabolic disease with a pathophysiology characterized by decreased insulin secretion and insulin resistance. There is substantial evidence for genetic components in the pathogenesis of the nonautoimmune forms of diabetes, specifically for the autosomal dominantly inherited maturity-onset diabetes of the young (MODY), where the impaired glucose regulation is due to a deficiency in pancreatic ß-cell insulin secretion. Several subtypes of MODY are recognized as being caused by single heterozygous mutations in genes encoding various transcription factors: hepatocyte nuclear factors (HNFs), along with insulin promoting factor-1, neurogenic differentiation factor D, and the glycolytic enzyme glucokinase (GCK) (17). Mutations in the known MODY genes explain only 5070% of all MODY cases (810). Thus, other genes, so-called MODY-X genes, are needed to explain the remaining MODY cases. A targeted knock-out of the novel oxidoreductase Ncb5or in mice was recently reported in which it was shown that homozygous Ncb5or/ mice developed a diabetic phenotype (11). The enzyme is a widely expressed cytosolic cytochrome b-type NAD(P)H oxidoreductase containing cytochrome b5 and b5 reductase domains (12). Young Ncb5or/ mice (aged 4 weeks) had impaired glucose tolerance and low insulin secretion, and after 7 weeks a considerable rise in blood glucose levels was observed when compared with Ncb5or+/+ mice. Ncb5or+/ heterozygote mice had normal blood glucose levels and normal glucose tolerance (NGT). For older Ncb5or/ mice there was a modest reduction in the number of islets, which in addition were distinctly depleted of ß-cells. Furthermore, islets from 4-week-old Ncb5or/ mice showed a 40% decrease in insulin content compared with size-matched islets from Ncb5or+/+ mice. Ncb5or/ mice at age 7 weeks also had elevated serum triglycerides and cholesterol levels and were hyperphagic (11).
Since absence of Ncb5or expression resulted in a diabetic phenotype with a noninflammatory ß-cell deficiency, we hypothesized that variation in human NCB5OR might be related to MODY-X or type 2 diabetes. Furthermore, owing to the relatively low age at the development of the phenotype, we included various early-onset diabetes subtypes in this supposition. Indeed, in a genome-wide scan (13) of MODY-X families, a linkage peak was identified on chromosome 6 (flanked by markers D6S1017 and D6S460) close to the chromosomal localization of human NCB5OR (6q14.2). Moreover, a genome-wide scan of Finnish affected sibling pairs showed strong linkage of a region on chromosome 6 close to NCB5OR with late-onset type 2 diabetes and HDL/total cholesterol ratios (14). In this study we investigated the entire coding region of human NCB5OR, including intron-exon boundaries for variation using denaturing high-performance liquid chromatography (dHPLC) and subsequent nucleotide sequencing in 183 diabetic patients including probands from MODY-X families, early-onset type 2 diabetic patients, late-onset type 2 diabetic patients, and women diagnosed with gestational diabetes mellitus (GDM). A total of 22 variants were identified (Fig. 1). Three variants were further investigated by genotyping in a group of 717 type 2 diabetic patients and in a group of 529 control subjects with NGT. The Gln187Arg (identified in one patient) and His223Arg (in four patients) variants were chosen due to their potential impact on NCB5OR protein function and the IVS5+7del(CT) (one patient) variant because it is located near a predicted splice site and may therefore influence mRNA expression and/or stability. The most frequent variant was IVS1472T>C with a minor allele frequency (MAF) of
Genotyping of the Gln187Arg variant did not result in the identification of any additional carriers among a total of 1,246 subjects. The patient for whom the variant was detected was a 49-year-old woman diagnosed with GDM during her second pregnancy at age 38 years. To examine a potential impact of the Gln187Arg variant on GDM, we genotyped a group involving 140 women with GDM; however, still no carriers of the variant were found. We carried out case-control studies for the His223Arg and IVS5+7del(CT) variants (Table 1). For the His223Arg variant we observed no differences between the diabetic patients and the control subjects for genotypic distribution or MAF. For the IVS5+7del(CT) variant the allele frequency was 0.3% (95% CI 0.00.6) for the type 2 diabetic patients and 1.0% (0.41.6) for the glucose-tolerant subjects. This difference was statistically significant (P = 0.03), which was also the case for the distribution of the genotype groups (P = 0.03, Table 1). For the diabetic patients, no differences were observed in age of onset, BMI, waist circumference, fasting serum C-peptide, or treatment between carriers and noncarriers of the IVS5+7del(CT) variant (data not shown).
For both the His223Arg and IVS5+7del(CT) variants we performed a study in the group of 529 glucose-tolerant subjects of the interaction between genotype groups and a range of quantitative traits related to type 2 diabetes and obesity (Table 2). We did not observe any significant associations for any of the phenotypes with the genotype group, and because there were no homozygous carriers, a tendency toward significant alterations in the metabolic variables was difficult to detect. One characteristic feature of the Ncb5or/ knock-out mice was an increase in circulating triglyceride and cholesterol levels (11). We observed a lower fasting serum total cholesterol level among the 10 carriers of the IVS5+7del(CT) variant and the four His223Arg heterozygotes, although this was not significant (Table 2). In addition, the IVS5+7del(CT) carriers had slightly lower fasting serum triglyceride and insulin levels, although this did not reach statistical significance either.
Two single nucleotide polymorphisms (SNPs) identified in an in silico search (rs1408932 and rs10080628) were not observed among 1,246 participants, and we assume that they are artifacts from sequencing of the chromosome 6 clones. Three intronic variants (IVS489A>T, IVS5131T>C, and IVS659A>G) were identified in only one patient each. These patients were the probands of three MODY-X families, and although these variants are unlikely to have any functional impact on NCB5OR, they may be in linkage disequilibrium with a yet unidentified causative variant located outside the area included in the present mutation analysis. DNA was obtained from the remaining family members who were genotyped for the respective variants using nucleotide sequencing and examined in a cosegregation study with disease status. No evidence of cosegregation with the MODY diabetes subtype was found in the three families (data not shown). A fourth intronic variant (IVS795G>A) was identified only in a proband from a family with early-onset type 2 diabetes and was investigated in a similar manner; however, no evidence of cosegregation with disease status or age of disease onset was observed in this family (data not shown). Furthermore, one MODY-X family that was examined in the mentioned genome scan (13) and contributed to the chromosome 6 linkage peak was also included in the present mutation analysis. No variants were observed in this family. The observation that homozygous Ncb5or/ knock-out mice present with an early-onset diabetic phenotype with a ß-cell defect as a primary observation makes human NCB5OR a credible biological candidate gene for a mutation analysis in relation to type 2 diabetes and various diabetes subtypes related to ß-cell dysfunction. This is further strengthened by evidence from a MODY-X and an affected sibling pair genome scan showing linkage with a chromosomal area close to the NCB5OR locus (13,14).
Alignment of the Gln187Arg and His223Arg variants showed that both the Gln- and His-alleles were conserved between the human and murine NCB5OR proteins. All three amino acids are polar and hydrophilic, but whereas histidine and arginine are both positively charged and an exchange of these is not considered to confer a major change in the protein function as such, the glutamine to arginine substitution results in a change from an amide to an alkaline amino acid. The His223Arg variant is located in the b5 reductase domain of NCB5OR and the Gln187Arg variant in the hinge region connecting the cytochrome b5 and b5 reductase domains. The Gln187Arg substitution was genotyped in 1,246 participants; however, no additional carriers were identified. The patient for whom the variant was originally identified was a woman diagnosed with glucose intolerance during her second pregnancy. In pregnancies complicated by GDM the increased demand for insulin due to impaired tissue insulin sensitivity is not readily met because of reduced pancreatic ß-cell function (rev. in 15). Furthermore, a positive family history of diabetes may pose an increased risk of developing GDM in women >30 years of age (16). We genotyped 140 women with GDM in order to investigate the role of the Gln187Arg variant in GDM, but we failed to identify any additional carriers. At the time of her examination, the 49-year-old patient had a BMI of The His223Arg variant did not show any association with type 2 diabetes or diabetes-related intermediary phenotypes. On the contrary, the IVS5+7del(CT) variant had a lower frequency among type 2 diabetic patients than among glucose-tolerant subjects and correspondingly a slightly lower relative number of mutation carriers. However, none of the quantitative traits investigated in this study were significantly associated with the variant, although we did observe some suggestive tendencies in fasting serum lipid and insulin levels. For both of the variants this may be due to the low allele frequency and the resulting relatively low power to detect quantitative trait differences; larger study populations are clearly needed. Also, there is a need for replication of the initial finding of an association between the IVS5+7del(CT) variant and type 2 diabetes. The observation that the IVS5+7del(CT) variant confers a modestly reduced risk of developing type 2 diabetes is somewhat counterintuitive, and considering the total number of tests performed in the present study a correction for multiple testing is appropriate. Consequently, the differences in allele frequencies and genotype distribution are not statistically significant. Moreover, we were unable to ascertain a specific metabolic phenotype for this observation. Thus, we conclude that the IVS5+7del(CT) variant is not an important contributor in the pathogenesis of type 2 diabetes in the examined population. A putative relationship between NCB5OR and MODY of as yet unknown genetic cause was investigated by analyzing 63 MODY-X patients for mutations and genotyping all promising variants in the patients family members. However, there was no evidence in the present study to suggest that variation in NCB5OR is involved in MODY or early-onset type 2 diabetes. The assessment of NCB5OR as a positional candidate gene for MODY was also done by including one MODY-X family in the mutation analysis, which contributed to the previously described chromosome 6 linkage peak. Likewise, this part of the study did not point to any role of NCB5OR in the etiology of MODY. A limitation to this conclusion is, however, that variation in regulatory sequences in the NCB5OR locus may exist and possibly have an impact on the expression of the protein, thereby influencing diabetes-related traits.
Even though the Ncb5or/ mice presented with a very convincing nonautoimmune diabetic phenotype, the lack of an association between the identified NCB5OR variants and type 2 diabetes and/or quantitative phenotypic traits could be explained by the fact that the heterozygote Ncb5or+/ mice had NGT. On the contrary, for the Hnf1 In summary, we discovered a total of 22 novel nucleotide variants in NCB5OR, and in epidemiological studies we invstigated a selection of these variants along with two additional SNPs identified in silico. The IVS5+7del(CT) variant showed significant association with type 2 diabetes in a case-control study, but we failed to relate this finding with prediabetic and/or obesity-related quantitative traits. Further studies of this variant are needed and may involve functional in vitro studies and genotyping of the variant in even larger study samples in order to explore its role in NCB5OR function and expression.
Mutation analysis was performed in three patient groups. The first group consisted of 61 late-onset type 2 diabetic patients (36 men and 25 women) recruited from the outpatient clinic at Steno Diabetes Center. The mean age of the patients was 62 ± 11 years (mean ± SD), age at diagnosis 54 ± 10 years, BMI 29.9 ± 4.8 kg/m2, and HbA1c 8.1 ± 1.7%. The patients were treated with diet alone (27%), oral hypoglycemic agents (OHAs) (58%), or insulin alone or in combination with OHAs (15%). The second group, which was also recruited from Steno Diabetes Center, consisted of 59 type 2 diabetic patients with age of onset before 40 years (38 men and 21 women) including 6 women with an earlier diagnosis of GDM. The mean age of the patients was 47 ± 10 years, mean age at diagnosis 37 years (range 2140), BMI 29.6 ± 6.0 kg/m2, and HbA1c 8.3 ± 1.7%. The patients were treated with diet alone (25%), OHAs (57%), or insulin alone or in combination with OHAs (18%). The third group involved 63 MODY-X patients (32 men and 31 women) recruited from pediatric and endocrinology departments in Denmark. The mean age of the patients was 34 ± 14 years, mean age at diagnosis 17 years (range 925), BMI 25.0 ± 4.6 kg/m2, and HbA1c 7.5 ± 1.8%. The patients were treated with diet alone (33%), OHAs (6%), or insulin alone or in combination with OHAs (61%). The patients were excluded for mutations known to be present in the MODY genes TCF1, HNF4A, and GCK. In these probands diabetes was present in three consecutive generations or in two generations if cousins of the patients were also affected. The case-control study was performed in unrelated type 2 diabetic patients recruited from the out-patient clinic at Steno Diabetes Center and in unrelated NGT subjects sampled at random during 1994 through 1997 at Steno Diabetes Center and Research Centre for Prevention and Health (20). In the group of type 2 diabetic patients (n = 717, 448 men and 269 women) the mean age was 59 ± 10 years, age at diagnosis 53 ± 10 years, BMI 29.1 ± 5.1 kg/m2, and HbA1c 8.1 ± 1.7%. The patients were treated with diet (37%), OHAs (53%), or insulin alone or in combination with OHAs (10%). In the group of glucose-tolerant subjects (n = 529, 248 men and 281 women) the mean age was 57 ± 10 years and BMI 25.8 ± 3.7 kg/m2. The group of 140 women with previous GDM was randomly selected from a population of 376 women with GDM diagnosed during 1978 through 1996 at the Department of Diabetes and Pregnancy, Rigshospitalet, Copenhagen University Hospital (21). The mean age at diagnosis of GDM was 32 ± 5 years, and during pregnancy the patients were treated with diet (94%) or insulin (5%). Diabetes was diagnosed according to 1999 World Health Organization criteria (22). All control subjects underwent a standard 75-g OGTT. All participants were Danish Caucasians by self-report. Informed written consent was obtained from all subjects before participation. The study was approved by the Ethical Committee of Copenhagen and was in accordance with the principles of the Declaration of Helsinki II.
Biochemical assays.
Mutation detection.
Genotyping. The His223Arg variant was genotyped by restriction fragmentlength polymorphism (RFLP)-PCR (2 mmol/l MgCl2, Tanneal 58°C) with forward primer 5'-ACG TTT TGT CTT GAG GGA TTT-3' and reverse primer 5'-CAT CTT TGT TTT GCA ATG TGA-3' followed by digestion with NlaIII. The Gln187Arg variant was genotyped by restriction site generating (RG) PCR-RFLP (2 mmol/l MgCl2, Tanneal 55°C) with forward RG primer 5'-GTC ACC ATT GCC ATA TAT ACT AA -3' and reverse RG primer 5'-CTG AGT TCC AAA TGC C G-3' (mismatched nucleotides are underlined) followed by digestion with HpaII. The IVS5+7(CT)del variant was genotyped using RG PCR-RFLP (1.5 mmol/l MgCl2, Tanneal 50°C) with forward RG primer 5'-GAA AGT CTT AAA TGG A GT-3' and reverse primer 5'-GGA GGT TAC AGT GAG CTG AG-3' followed by digestion with AatII. This assay does not contain an internal restriction site for control of digestion; however, all heterozygous carriers of the deletion were assayed twice for verification of their genotype, and no discrepancies were detected. No homozygous carriers of the deletion were identified. The rs1408932 A/G variant was genotyped using RG PCR-RFLP (2 mmol/l MgCl2, Tanneal 58°C) with forward primer 5'-TGA GCT AGT TGA AAA TTT GAG CA-3' and reverse RG primer 5'-AAG TTG AGA TCA TGC AGC A -3' followed by digestion with MboI. The rs10080628 variant was genotyped using RG PCR-RFLP (2 mmol/l MgCl2, Tanneal 55°C) with forward RG primer 5'-GGC AAC ATG TTT ACC TCA AG T-3' and reverse primer 5'-ACA CGT TGC AGT CAC AAA CC-3' followed by digestion with RsaI. All restriction enzyme digests were separated on 4% agarose gels and visualized by ethidium bromide staining.
Statistical analysis.
In silico data analysis.
This study was supported by the Danish Medical Research Council, the Danish Diabetes Association, the Danish Heart Foundation, the Velux Foundation, and the European Economic Community (BMH4-CT98-3084 and QLRT-CT-1999-00 546). The authors thank Professor P.D. Meyts for valuable supervision of G. Andersens PhD project. Address correspondence and reprint requests to Gitte Andersen, MSc, Steno Diabetes Center and Hagedorn Research Institute, Niels Steensens Vej 2, NSH2.16, DK-2820 Gentofte, Denmark. E-mail: gtta{at}steno.dk Received for publication June 1, 2004 and accepted in revised form July 21, 2004
Abbreviations: dHPLC, denaturing high-performance liquid chromatography; GCK, glucokinase; GDM, gestational diabetes mellitus; HNF, hepatocyte nuclear factor; MAF, minor allele frequency; MODY, maturity-onset diabetes of the young; NCBI, National Center for Biotechnology Information; NGT, normal glucose tolerance; OGTT, oral glucose tolerance test; OHA, oral hypoglycemic agent; RFLP, restriction fragmentlength polymorphism; RG, restriction site generating; SNP, single nucleotide polymorphism
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