Recurrence of Graves' Disease: What Genetics of HLA and PTPN22 Can Tell Us.

Background: Approximately half of patients diagnosed with Graves' disease (GD) relapse within two years of thyreostatic drug withdrawal. It is then necessary to decide whether to reintroduce conservative treatment that can have serious side effects, or to choose a radical approach. Familial forms of GD indicate a significant genetic component. Our aim was to evaluate the practical benefits of HLA and PTPN22 genetic testing for the assessment of disease recurrence risk in the Czech population. Methods: In 206 patients with GD, exon 2 in the HLA genes DRB1, DQA1, DQB1 and rs2476601 in the gene PTPN22 were sequenced. Results: The risk HLA haplotype DRB1*03-DQA1*05-DQB1*02 was more frequent in our GD patients than in the general European population. During long-term retrospective follow-up (many-year to lifelong perspective), 87 patients relapsed and 26 achieved remission lasting over 2 years indicating a 23% success rate for conservative treatment of the disease. In 93 people, the success of conservative treatment could not be evaluated (thyroidectomy immediately after the first attack or ongoing antithyroid therapy). Of the examined genes, the HLA-DQA1*05 variant reached statistical significance in terms of the ability to predict relapse (p=0.03). Combinations with either both other HLA risk genes forming the risk haplotype DRB1*03-DQA1*05-DQB1*02 or with the PTPN22 SNP did not improve the predictive value. Conclusion: the DQA1*05 variant may be a useful prognostic marker in patients with an unclear choice of treatment strategy.

[Primary hyperparathyroidism - new clinical forms of the disease]. / Primární hyperparatyreóza - nové klinické formy onemocnení.

Primary hyperparathyroidism (PHPT) has been increasingly diagnosed incidentally in its asymptomatic form owing to calcium screening tests. This form of PHPT represents 80% in developed countries. Although PHPT patients are asym-ptomatic, target organ (bone and kidney) involvement is frequently observed. Mild PHPT is associated with a reduction of bone mineral densityand, moreover, with increased risk of vertebral fractures. The extent of a patient evaluation and indications for parathyroidectomy are based on expert guidelines from 2014. Normocalcemic variant of PHPT has been recently recognized, possibly with higher prevalence in general population than the hypercalcemic form of PHPT. Normal but with respect to hypercalcemia inadequately high parathormon levels characterize normohormonal PHPT. If a hereditary form of PHPT is suspected, genetic testing is recommended. Although there are new clinical forms of PHPT, parathyroidectomy still represents the only curative approach to PHPT followed by substantial osteoprotective effect.Key words: asymptomatic form - normocalcemic form - normohormonal form - parathyroidectomy - primary hyperparathyroidism - recent guidelines for the management PHPT.

[Hypercalcemia, symptoms, differential diagnostics and treatment, or importance of calcium investigation]. / Hyperkalcemie, príznaky, diferenciální diagnostika a lécba aneb dulezitost vysetrování kalcia.

UNLABELLED: The concentration of calcium is carefully maintained under physiological conditions with parathormone, calcitonin and 1,25-dihydroxyvitamin D at appropriate levels. There are multiple causes that may bring about increased concentrations of calcium which exceed physiological values. Increased production of parathormone in parathyroid glands is only one of the possible causes. Malignant diseases are a very frequent cause of hypercalcemia, due to their creating mediators which stimulate osteoclasts and thereby osteolysis. A less frequent cause is represented by granulomatous processes, a typical example of which is sarcoidosis, whose cells increasingly (independently of parathormone) hydroxylate 25-hydroxyvitamin D to 1,25-dihydroxyvitamin D. However there are also hereditary forms of hypercalcemia. One of the causes of the hereditary form of hypercalcemia is mutations of the calcium sensing receptor. In order to locate the adenoma of parathyroid glands, essential apart from sonographic imaging is scintigraphy 99mTc-methoxyisobutylisonitrile (MIBI) and even more exact is PET-CT examination with a radio-pharmaceutical 18F-fluorocholine. PET-CT examinations are beneficial with regard to detecting a malignant cause of hypercalcemia in until then undetected malignancy or an undetected granulomatous process. The essential treatment procedures for malignant hypercalcemia include appropriate hydratation of ionic solutions without calcium, administering of bisphosphonates or denosumab. The text describes in detail the symptoms of hypercalcemia and diagnostics of causes of hypercalcemia. KEY WORDS: bisphosphonates - cinacalcet - denosumab - granulomatous diseases - hereditary hypercalcemia - hypercalcemia - hypercalciuria - hyperparathyreosis - calcimimetics - calcitonin - multiple myeloma - malignant hypercalcemia - parathormone - sarcoidosis - 1,25-dihydroxyvitamin D.

[Primary hyperparathyroidism as a cause of hypercalcemia in a patient with breast cancer]. / Primární hyperparatyreóza jako prícina hyperkalcémie u pacientky s karcinomem prsu.

Hypercalcemia associated with breast cancer arises either from metastatic bone disease or from paraneoplastic secretion of parathyroid hormone-related peptide. We report a female 69-year-old patient with invasive intraductal breast cancer and hypercalcemia (3,4 mmol/l) referred to endocrinologist. Standard care in oncology was refused and with respect to the presence of estrogenic receptors the patient accepted only antiestrogenic treatment. Bone scan revealed no skeletal metastasis. Entry laboratory exam confirmed hypercalcemia, hypophosphatemia and significantly elevated parathyroid hormone (793 ng/l). The patient complained of bone pain and dyspepsia. Neck ultrasound showed a multinodular goiter with particularly enlarged left lobe. Parathyroid gland scintigraphy revealed a possible parathyroid adenoma behind the lower pole of the left thyroid lobe. The patient underwent thyroidectomy with an excision of the parathyroid mass. Microscopic examination identified a benign adenomatous goitre and benign parathyroid adenoma. Postoperatively, both serum calcium and parathyroid hormone normalized. Replacement of calcium and vitamin D were initiated both with bisphosphonate with regard to newly diagnosed osteoporosis. This case demonstrates a patient with breast cancer and hypercalcemia unrelated to the malignant disease. Primary hyperparathyroidism should be considered as a possible cause of hypercalcemia in breast cancer patients in the setting of negative bone scan, elevated parathyroid hormone and mildly deteriorated bone mineral density.

Low-density lipoprotein receptor-related protein-5 C/T polymorphism in exon 18 is associated with C peptide and proinsulin levels in control women and patients with polycystic ovary syndrome.

OBJECTIVE: To assess the previously unstudied potential role of C/T (A1330V) polymorphism of the low-density lipoprotein receptor-related protein-5 gene in insulin sensitivity and secretion in polycystic ovary syndrome. The low-density lipoprotein receptor-related protein-5 gene has been found to play a role in determining insulin secretion in animal models. DESIGN: Case-control study. SETTING: Tertiary outpatient clinic. PATIENT(S): Women with polycystic ovary syndrome (n = 299; age, 27.5 +/- 7.1 y [mean +/- SD]), according to the European Society of Human Reproduction and Embryology criteria, as well as healthy control women (n = 187, age, 28.9 +/- 9.8 y). INTERVENTION(S): Oral glucose tolerance test, blood sampling. MAIN OUTCOME MEASURE(S): Glucose, insulin, C peptide, proinsulin during oral glucose tolerance tests, and lipids. Genotyping of C/T (A1330V) polymorphism by polymerase chain reaction-restriction fragment length polymorphism. RESULT(S): There was no difference in the frequency of genotypes between women with polycystic ovary syndrome (CC/CT/TT: 80.3%, 18.4%, 1.3%) and the control women (79.1%, 19.8%, and 1.1%). Carriers of the T allele had statistically significantly higher basal and stimulated C peptide and proinsulin levels than CC homozygotes, both basally and at the 180th minute. Regarding insulin sensitivity, there was no difference between T carriers and CC homozygotes. CONCLUSION(S): Polymorphism of C/T in the low-density lipoprotein receptor-related protein-5 gene is associated with C-peptide and proinsulin secretion but does not influence insulin sensitivity in either healthy women or women with polycystic ovary syndrome.

Identification and functional characterization of a novel mutation in the calcium-sensing receptor gene in familial hypocalciuric hypercalcemia: modulation of clinical severity by vitamin D status.

CONTEXT: Familial hypocalciuric hypercalcemia (FHH) is a benign condition associated with heterogeneous inactivating mutations in the calcium-sensing receptor (CASR) gene. OBJECTIVE: The objective of the study was to identify and characterize a CASR mutation in a moderately hypercalcemic, hyperparathyroid individual and his family and assess the influence of vitamin D status on the clinical expression of the defect. SUBJECTS: We studied a kindred with FHH, in which the proband (a 34-yr-old male) was initially diagnosed with primary hyperparathyroidism due to frankly elevated serum PTH levels. METHODS: CASR gene mutation analysis was performed on genomic DNA of the proband and family members. The mutant CASR was functionally characterized by transient transfection studies in kidney cells in vitro. RESULTS: A novel heterozygous mutation (F180C, TTC>TGC) in exon 4 of the CASR gene was identified. Although the mutant receptor was expressed normally at the cell surface, it was unresponsive with respect to intracellular signaling (MAPK activation) to increases in extracellular calcium concentrations. The baby daughter of the proband presented with neonatal hyperparathyroidism with markedly elevated PTH. Vitamin D supplementation of both the proband and the baby resulted in reduction of serum PTH levels to the normal range. The serum calcium level remained at a constant and moderately elevated level. CONCLUSION: The identification of a novel CASR gene mutation established the basis of the hypercalcemia in the kindred. Concomitant vitamin D deficiency modulates the severity of the presentation of FHH.

Low-density lipoprotein receptor-related protein 5 and vitamin D receptor gene polymorphisms in relation to vitamin D levels in menopause.

BACKGROUND: The low-density lipoprotein receptor-related protein 5 (LRP5) gene has been recently identified as a novel candidate for osteoporosis. The c.4037C>T polymorphism in the LRP5 gene has been associated with bone mass variance in general population. In contrast, the IVS8+443G>A polymorphism in the vitamin D receptor gene (VDR) has not been investigated in relation to bone metabolism. The aim of the present study was to determine VDR IVS8+443G>A and LRP5 c.4037C>T polymorphisms in a cohort of 165 perimenopausal women and to associate the genotypes with biochemical and densitometric bone parameters in a subset of 112 postmenopausal women. METHODS: Both polymorphisms were assessed by restriction analysis of the PCR product. Calcium, parathyroid hormone, vitamin D metabolites and bone mineral density (BMD, g/cm(2)) at the hip and in the spine (L(1)-L(4)) were examined. RESULTS: The genotype frequencies of both IVS8+443G>A (UU 75.2%, Uu 23%, uu 1.8%) and c.4037C>T (CC 73.9% TC 23.6%, TT 2.4%) were comparable to other Caucasian female cohorts. Serum 25OH vitamin D levels, assessed in only 63 probands, were significantly associated with VDR genotypes (ANCOVA, pA polymorphism was significantly associated with circulating 25OH vitamin D in postmenopausal Caucasian women. The role of candidate gene polymorphisms in the vitamin D metabolic pathway requires further investigation.

Vitamin D receptor polymorphisms, bone ultrasound and mineral density in post-menopausal women.

BACKGROUND AND AIMS: Bone structure, geometry and mineral content represent complex traits with a significant heritable component. However, the specific contributing genes have not been unambiguously identified. The aim of the present cross-sectional study was to analyse an association between heel ultrasound measurements, partly reflecting bone quality, and VDR (Vitamin D receptor) gene polymorphisms in post-menopausal women, and to assess whether these associations differ from those of bone density or not. METHODS: BUA (broadband ultrasound attenuation, dB/MHz) at the right heel and BMD (bone mineral density, g/cm2) at the lumbar spine and hip were measured in 114 post-menopausal women of Caucasian origin (62.4 +/- 9.8 years). All probands were genotyped for common VDR polymorphisms--FokI, BsmI, Apal and TaqI--by restriction analysis of the PCR product. RESULTS: ANCOVA revealed significant associations between calcaneal BUA adjusted for BMI (body mass index) and YSM (years since menopause), and BsmI, Apal and TaqI genotypes in the VDR gene (p < 0.02; p < 0.0003; p < 0.02 ANCOVA, respectively). BMI- and YSM-adjusted BMD was significantly associated with Fokl genotypes in the VDR gene (p < 0.028 at lumbar spine, p < 0.007 at hip). CONCLUSIONS: The present data show that post-menopausal BMD and BUA are determined by different polymorphisms within the VDR gene. Non-coding polymorphisms in the 3' end of the VDR gene (BsmI, Apal, TaqI) are related to heel ultrasound while the FokI polymorphism in exon 2, located at the opposite site of the VDR gene, is associated with BMD measurements. Further studies are required to determine whether different polymorphic markers within a single gene independently determine various components of post-menopausal bone.

Osteoporosis: genetic analysis of multifactorial disease.

Osteoporosis is a common disorder with a complex pathophysiology involving both endogenous and environmental factors. Family and twin studies have shown that genetic factors play an essential role in bone mass regulation and that apart from rare instances the heritability of bone mineral density (BMD) and osteoporosis is polygenic. Linkage analysis and association studies with numerous DNA markers (single nucleotide polymorphisms or microsatellites) have analysed several bone-related candidate genes encoding vitamin D, calcium-sensing, calcitonin and estrogen alpha receptors, insulin growth factor I, collagen type I alpha 1 chain and others. Despite this, the definite polymorphic marker has not been found in different populations which reflects the divergent results of association studies with their frequent limitations, and probably the fact that the relevant polymorphism is still awaiting identification. Once the genetic determinants can be defined, the clinical implications would be extensive both in diagnostics and in pharmacogenetics.

Apolipoprotein E gene determines serum testosterone and dehydroepiandrosterone levels in postmenopausal women.

OBJECTIVE: Apolipoprotein E (ApoE) is believed to play an important role in lipid metabolism and has been found to be related to diseases associated with ageing, the important characteristic of which is decline in circulating sex steroids, including androgen. DESIGN: To find the relationships of levels of serum testosterone and its precursor, dehydroepiandrosterone (DHEA), to ApoE polymorphism in 113 postmenopausal Caucasian women. METHODS: The ApoE genotype was assessed by polymerase chain reaction and CfoI endonuclease digestion. ApoE genotype distribution was as follows: E2/3, 15%; E3/3, 71.7%; E2/4, 1.8%; E3/4, 10.6; and E4/4, 0.89%. The differences in serum androgen levels between genotypes were evaluated by ANCOVA and least significant difference (LSD) multiple comparisons test after adjustment for body mass index, age and/or years since menopause. RESULTS: Significant intergroup differences between the most frequent allele combination (2/3, 3/3 and 3/4) in serum DHEA levels were found (P<0.05, ANCOVA). DHEA levels were higher in women with the E3/4 allele combination than in the E3/3 genotype (P<0.01, LSD multiple comparisons). In serum testosterone levels, borderline intergroup differences were found (P<0.07, ANCOVA). Higher testosterone levels were found in the E3/4 allele combination as compared with E3/3 (P<0.05, LSD multiple comparisons). Dose effect of E4 allele analysis indicated higher serum DHEA and testosterone levels in women with the E4 allele present than in women with the E4 allele absent (P<0.003 for DHEA, P<0.007 for testosterone, ANCOVA). CONCLUSIONS: Circulating testosterone and DHEA are associated with the ApoE genotype, which may render women carrying the allele E4 more susceptible to the development of some diseases associated with ageing and menopause [corrected].