DNA variations, impaired insulin secretion and type 2 diabetes 7398 words Valeriya Lyssenko, M.D., Ph.D and Leif Groop, M.D., Ph.D Department of Clinical Sciences / Diabetes & Endocrinology and Lund University Diabetes Centre, Lund University, University Hospital Malmö, Malmö, Sweden Address: Valeriya Lyssenko, M.D, Ph.D, Department of Clinical Sciences/Diabetes & Endocrinology Lund University University Hospital Malmö 20502 Malmö Sweden Phone: 46-40-391214 E-mail: Valeri.Lyssenko@med.lu.se 1 Abstract The success in dissecting the genetics of complex polygenic diseases like type 2 diabetes (T2D) until now has not been a trivial task. The picture has dramatically changed during the past years with the introduction of genome wide association studies (GWAS). Today we know about 30 genetic variants increasing risk of T2D or influencing glucose/insulin levels. Most of them seem to influence the capacity of cells to increase insulin secretion to meet demands imposed by increase in body weight and insulin resistance. This probably only represents the tip of the iceberg and refined tools will over the next few years provide a more complete picture of the genetic complexity of T2D. This will not only include the current dissection of common variants increasing susceptibility for the disease but also rare variants with stronger effects. For the first time we can with some confidence anticipate that the genetics of a complex disease like T2D really can be dissected. Key words: genetics, complex disease, polygenic, linkage study, genome wide scan, association study, single nucleotide polymorphism, insulin section, beta cell function. 2 1 Introduction 1.1. Evidence that type 2 diabetes is inherited There is ample evidence that type 2 diabetes (T2D) has a strong genetic component. The risk of developing T2D is approximately 3-fold increased in first-degree relatives of a patient with T2D compared to subjects without family history of diabetes, this value is often referred to as the sibling-relative risk, s value around 3.5 [1]. If one parent has diabetes the risk that offspring will develop the disease is about 40%, and if both parents have diabetes the risk is approximately 70% [2]. Intriguingly, the risk in the offspring seems to be greater if the mother rather than the father has T2D [3]. Very high concordance rate rates of T2D have been reported in monozygotic twins of 70% compared with 20-30% in dizygotic twins [4, 5]. Thus, approximately of 70% of the variability of diabetes maybe heritable. It is clear that the change in the environment towards a more affluent Western life style plays a key role in the epidemic increase in the prevalence of T2D worldwide. This change has occurred during the last 50 years, during which period our genes have not changed. This does not exclude an important role for genes in the rapid increase in T2D, since genes or variation in them explain how we respond to changes in the environment and the environment always imposes a selective pressure on genes. An example of such selective pressure is the mutation of Lac gene causing lactase persistance, i.e. ability to drink and absorb cow milk as adults with the domestication of cattle [6]. The hypothesis that thrifty genes could be a plausible explanation for the interaction between genes and environment was first introduced by Neel in 1962 [7]. During a long time of evolution humans have been subjected to long periods of famine and unpredictable food supplies. Neel proposed that individuals living in an environment with unstable food supply (as for hunters and nomads) would maximize their probability of survival if they could maximize storage of energy. Genetic selection would thus favor energy-conserving genotypes in such environments. An alternative explanation has been proposed by which these changes can be the consequence of intrauterine programming, the so called thrifty phenotype hypothesis [8]. The reason for this could be that poor intrauterine nutrition 3 permanently programs the body to a constant starvation-state, which would lead to a low birth weight and increased risk of T2D later in life. However, a low birth weight could also be a consequence of impaired -cell function. Children with a glucokinase defect have a decrease in insulin secretion and a low birth weight if they inherit mutation from the father [9]. Carriers of glucokinase mutation can secrete insulin, but their beta-cells have a higher glucose threshold for glucose-stimulated insulin secretion. This was particularly apparent in children of diabetic mothers, since these children would be expected to have a high birth weight as a consequence of high glucose concentrations passing the placenta and thereby stimulating the fetal pancreas to produce increasing amounts of anabolic insulin. 1.2. Risk factors predicting future T2D Although risk factors for T2D seem to differ between different ethnic populations, to a family history of diabetes consistently confers an increased risk of future T2D diabetes [1], however its relative effect decreases with increasing frequency of T2D in the population. Its predictive value is also relatively poor in young subjects whose parents have not yet developed the disease. Abdominal obesity and presence of the metabolic syndrome, and low level of physical activity confer an increased risk of T2D [10, 11]. However an impaired insulin secretion, especially when adjusted for the degree of insulin resistance, so called disposition index, is the strongest predictor of future T2D. We have demonstrated this using two large prospective studies, the Malmö Preventive Project (MPP) and the Botnia Prospective Study (BPS) over a more than 25-year follow-up period. In both studies, obesity and a low insulin secretion when adjusted for insulin resistance was strongly associated with increased risk of future T2D, and this risk was doubled in individuals with a family history of diabetes (Figure 1) [12]. Whether a family history of diabetes can be replaced by genetic testing in the prediction of T2D will be shown later. 1.3. Genetic variability Mapping of an inherited disease implies the identification of the genetic variability contributing to the disease. Such variability can be deletions, insertions or changes in a single nucleotide in the genome, single nucleotide polymorphism (SNP). If a SNP 4 results in a change in the amino acid sequence it is a called a non- synonymous SNP. There are about 10 million SNPs in the human 3 billion bp genome, which means one SNP at about 300 bp intervals. SNPs in coding sequences (exons) are seen at 1250 bp intervals. Microsatellites are short tandem repeats of nucleotide sequences (e.g. CA) found at about 5000 bp intervals. Whereas SNPs are frequently bi-allelic microsatellites have multiple alleles and are thus much more polymorphic than SNPs. Several public databases provide information on SNPs in different genes (e.g. www.ncbi.nlm.nig.gov/SNP. A SNP in a database is often referred to as dbSNP; at moment (build 123) about 60% of all SNPs are in public databases. A SNP can either be the cause of the disease (causative SNP) or it can be a marker of the disease. This occurs when the disease susceptibility allele and the marker allele are so close to each other that they are inherited together, a situation called linkage disequilibrium (LD or allelic association). Such a combination of tightly linked alleles on a discrete chromosome is called a haplotype. While this region is characterized by little or no recombination (haplotype block) regions with high recombination rate usually separate haplotype blocks. LD thus describes the nonrandom correlation between alleles at a pair of SNPs; it is usually defined by D’ or r2 values. A D’ value of 1 indicates that the two alleles are in complete LD, whereas values below 0.5 indicate low LD and a high recombination rate. LD extends over longer distances in isolated populations, but is also in European compared with African populations. This is considered to reflect a population bottleneck at the time when humans first left Africa. An international joint effort to create a genome-wide map of LD and haplotype blocks is called the HapMap project (http://www.hapmap.org/groups.html). The hope is that by knowing the haplotype block structure of the genome, one could capture the genetic variability of the genome by genotyping a much smaller number of SNPs that describe the haplotype block (haplotype tag or htg SNPs). 1.4. Mapping genetic variability Profiling genetic variation aims to correlate biological variation (phenotype) with variation in DNA sequences (genotype). The ultimate goal of mapping genetic variability is to identify the SNP causing a monogenic disease or the SNPs increasing susceptibility to a polygenic disease. The most straightforward approach would be to 5 sequence the whole genome in affected and unaffected individuals but this is for practical reasons not yet possible. Many indirect methods have been developed to achieve the goal like linkage and association approaches. 1.4. Linkage The traditional way of mapping a disease gene has been to search for linkage between a chromosomal region and a disease by genotyping a large number (about 400-500) of polymorphic markers (microsatellites) in affected family members. If the affected family members would share an allele more often than expected by non-random Mendelian inheritance, there is evidence of excess allele sharing. The most likely explanation for excess allele sharing is that a disease-causing gene is in close proximity to the genotyped marker. Ideally, such a genome wide scan would be carried out in large pedigrees where mode of inheritance and penetrance would be known. Since these parameters are not known and parents are rarely available in a complex disease with late-onset, most genome wide scans are performed in affected siblings with no assumptions on mode of inheritance and penetrance (non-parametric linkage). The LOD score defines the strength of linkage. This takes into account the recombination fraction (), which is the likelihood that a parent will produce a recombinant in an offspring. If the parental genotype is intact in the offspring, the recombination fraction is 0 (loci are linked), for completely unlinked loci it approaches 0.5. The probability test of linkage is called the LOD score (logarithm of odds). Two loci are considered linked when the probability of linkage as opposed to the probability against linkage is equal to or greater than the ratio of 1000/1. A LOD score of 3 corresponds to an odds ratio of 1000/1 (p<10-4). In a study of affected sib pairs a non-parametric LOD score (NPL) is presented. Although this threshold was developed for linkage mapping of monogenic disorders with complete information of genotype and phenotype, the situation for mapping complex disorders is much more complex. Lander and Kruglyak (5) have proposed that the LOD threshold for significant genome-wide linkage should be raised to 3.6 (p<2x10-5) while that for suggestive linkage (would occur one time at random in a genome wide scan) can be set at 2.2 (p<7x2-4). In addition, they suggest to report all nominal p values < 0.5 without any claim for linkage. In reality each data set will have different thresholds 6 based upon information on affection status, marker density, marker informativeness etc. Therefore, these thresholds should be simulated using the existing data set before any claims of linkage can be made. Accuracy of genotyping and exclusion of Mendel errors are important for the success but also the careful definition of affection status. This may not always be easy for disease like asthma, schizophrenia or systematic lupus erythematosus (SLE). Even for diabetes the definition is based upon man-made cut-offs of plasma glucose. Dichotomizing variables may result in loss of power. One alternative is therefore to search linkage to a qualitative trait, e.g. blood glucose, blood pressure body mass index instead of diabetes, hypertension and obesity. Heritability (h2) is often used as a measure of the genetic component of a quantitative trait. The higher the heritability, the more likely it is to find the genetic cause to the trait. Several statistical programs have been developed to support genome wide scans of quantitative trait loci (QTL) like the variance component (www.sfbr.org/sfbr/public/software/solarR) models and SOLAR Merlin (www.sph.umich.edu/csg/abecasis/Merlin/tour). Linkage will only identify relatively large chromosomal regions (often > 20 cM) with more than 100 genes. Fine mapping with additional markers can narrow the region further but at the end the causative SNP or a SNP in LD with the causative SNP has to be identified by an association study. Several approaches have been described to estimate whether an observed association can account for linkage [13]. Without functional support it is not always possible to know whether linkage and association represent the genetic cause of the disease. This can for many complex disorders require a cumbersome sequence of in vitro and in vivo studies. ADRA2A: The alpha2A adrenergic receptor (ADRA2A) has been known as a physiological mediator of adrenergic suppression of insulin release. It has previously been shown that Adra2A knock-out mice present with enhanced insulin secretion and hypoglycemia [14], and animals with cell-specific overexpression of Adra2A are glucose intolerant [15]. The diabetic Goto-Kakizaki (GK) rats display a major diabetes susceptibility locus on rat chromosome 1, called Niddm1 [16]. A 16 Mb portion of Niddm1, termed Niddm1i, confers defective insulin secretion and is homologous to a region on human chromosome 10 that has been strongly associated 7 with T2D [17, 18]. In a recent study, we have identified ADRA2A being overexpressed at the Niddm1i locus, and rats displayed elevated glucose levels which were paralleled by a profound reduction in insulin secretion [19]. Furthermore, we demonstrated that genetic variants in the ADRA2A gene in humans were associated with impaired early and second phase of insulin secretion, increased expression of both transcript and protein in human islets, and increased risk of T2D (Figure 2) [19]. This was the first time it was possible to merge genetic information from an animal model of T2D with genetic information in human T2D. Independently of these findings, a different variant in the ADRA2A gene has recently been associated with increased fasting glucose levels [20]. These findings could open up exciting possibilities for specific and tailor-made therapeutic intervention. 1.5. Association studies – candidate genes If there is a prior strong candidate gene for the disease, the best approach is to search for association between SNPs in the gene and the disease. This can either be a case control or nested cohort study. In a case–control study the inclusion criteria for the cases are predefined and thereafter matched individual controls are searched representing the same ethnic group as the cases. In a cohort study affected and unaffected groups are matched, not individuals. Ideally cohorts are population-based but often they represent consecutive patients from an outpatient clinic. It is preferable that controls are older than cases to exclude the possibility that they still will develop the disease. If cases and controls are not drawn from the same ethnic group, a spurious association can be detected due to ethnic stratification. One way to circumvent this problem is to perform a family-based association study. Distorted transmission of alleles from parents to affected offspring would indicate that the allele showing excess transmission is associated with the disease. The untransmitted alleles serve as control. This transmission disequilibrium test (TDT) represents the most unbiased association study approach but suffers from the drawback of low power, only transmissions from heterozygous parents are informative. The prerequisite of DNA from parents usually enrich for individuals with an earlier onset of the disease. 8 PPARG: Even screening only one gene for SNPs can represent a huge and expensive undertaking. The peroxisome proliferator-activated receptor-gamma (PPARG) gene on the short arm of chromosome 3 spans 83,000 nucleotides with 231 SNPs in public databases, 7 of them are coding SNPs. The gene encodes for a nuclear receptor, which is predominantly expressed in adipose tissue where it regulates transcription of genes involved in adipogenesis. In the 5’ untranslated end of the gene is an extra exon B that contains a SNP changing a proline in position 12 of the protein to alanine. The rare Ala allele is seen in about 15% of Europeans and was in an initial study shown to be associated with increased transcriptional activity, increased insulin sensitivity and protective against T2D [21]. Subsequently, there were a number of studies, which could not replicate the initial finding. Using the TDT approach we could show excess transmission of the Pro allele to the affected offspring [22]. We thereafter performed a meta-analysis combining the results from all published studies showing a highly significant association with T2D. The Pro12Ala polymorphism of the PPARG gene is until now the best replicated gene for T2D (p< 2x10-10) (Table 1). It also predicts future T2D, especially in individuals with body mass index > 30 kg/m2 and fasting plasma glucose > 5.5 mmol/l and in carriers of risk variants in the CAPN10 gene [23]. There is also a strong interaction with nutritional factors and the protective effect of the Ala allele is enhanced with a high intake of unsaturated fat [24]. This may not be too surprising as free fatty acids have been proposed as natural ligands for PPARG. KCNJ11: The ATP-sensitive potassium channel Kir 6.2 (KCNJ11) forms together with the sulfonylurea receptor SUR1 (ABCC8) an octamer protein that regulates transmembrane potential and thereby glucose-stimulated insulin secretion in pancreatic beta-cells. Closure of the K- channel is a prerequisite for insulin secretion. A Glu23Lys polymorphism (E23K) has been associated with T2D and a modest impairment in insulin secretion [25, 26]. In addition, an activating mutation in the gene causes a severe form of neonatal diabetes [27]. Whereas these neonatal mutations result in a 10-fold activation of the ATP-dependent potassium channel, the E23K variant results in only a 2-fold increase in activity [28]. TCF7L2: By far the strongest association with T2D is seen for SNPs in the gene encoding for the transcription factor-7-like 2 (TCF7L2) [17, 29]. TCF7L2 encodes for a transcription factor involved in Wnt signalling. Heterodimerization of TCF7L2 9 with -catenin induces transcription of a number of genes including intestinal proglucagon. It is clear that risk variants in TCF7L2 are associated with impaired insulin secretion, and an impaired incretin effect, i.e. impaired stimulatory effect of incretin hormones like GLP-1 and GIP on insulin secretion (Figure 3) [30, 31]. It is also possible that the gene is involved in proliferation of -cells in response to increased demands. At onset of diabetes, T2D patients show a markedly increased expression of TCF7L2 in their islets [30]. Since over-expression of TCF7L2 in human islets resulted in impaired insulin secretion it is unlikely that the increased expression is a consequence of a defect in the downstream pathway, it rather reflects a defect in transcription or translation of TCF7L2 itself. There is a unique splicing pattern of the TCF7L2 gene in human islets, where especially exon 4 including isoforms are abundant [32]. Intriguingly, there was a positive correlation between the amount of exon 4 in human islets and HbA1c. Despite the increased expression of TCF7L2 in islets it is not known whether risk variants in the gene cause increased or decreased Wnt signaling. On the other hand, in rodent islets disruption of TCF7L2 in islets also result in impaired insulin secretion [33]. It will be one of the greatest challenges to identify these mechanisms, as TCF7L2 undoubtedly represent a potential novel drug target in T2D. WSF1: The Wolfram syndrome 1 (WFS1) gene encodes for wolframin, a protein, which is defective in individuals with the Wolfram syndrome. This syndrome is characterized by diabetes insipidus, juvenile diabetes, optic atrophy and deafness. WFS1 gene was identified through candidate gene search of 1536 SNPs in 84 genes, and further replication in 9,533 cases and 11,389 controls [34]. Genetic variants in the WFS1 have been associated with impaired glucose- and GLP1 (glucagon-like peptide1) -stimulated insulin secretion [35-37]. Wfs1 knockout mice showed progressive beta cell loss and impaired insulin secretion [38]. We have recently demonstrated that expression of WFS1 gene is also perturbed in pancreatic islets and skeletal muscle [39]. However, WFS1 discovery also highlights some of the difficulties of candidate gene studies. We are limited by our own imagination and only 1 out of 84 candidate genes gave a positive result! 10 1.6. Genome wide association studies A problem in the field of genetics of complex diseases is the difficulty to replicate an initial association. The International HapMap Project (http://www.hapmap.org) and a public-private SNP consortium (http://www.ncbi.nlm.nih.gov) have provided a catalogue of 10 million common genetic variants in the human genome. With the improvement of genotyping technology it has become technically possible to genotype a large number of SNPs at affordable costs, which paved the way for the so called genome wide association studies (GWAS). In 2007 GWAS made a real breakthrough in the genetics of T2D applying DNA chips with > 500,000 SNPs in a large number of patients with T2D and controls [40]. In our collaborative study with the Broad Institute and Novartis (Diabetes Genetic Initiative, DGI) we performed a WGAS in 1464 patients with T2D and 1467 non-diabetic control subjects from Finland and Sweden. Prior to publication we shared the results with researchers from the FUSION (Finnish USA Study of NIDDM) and WTCCC (Welcome Trust Case Control Consortium) groups [41]. We only considered positive results, which were seen and replicated in all three studies, i.e. together with replication samples the results were based upon DNA from 32,000 individuals! Two other WGAS [42, 43] in T2D have been published in the past year supporting and complementing our results. Notably, TCF7L2 was on top of each WGAS with a joint p value in the three scans of 10 –50 [29]. Several of the new genes seem to influence -cell proliferation by interfering with the cell cycle e.g. CDKAL1 and CDKN2A/CDKN2B. It has also become evident that some of the same SNPs which increase risk of or protect against T2D increase susceptibility to certain cancers like in the prostate and in colon [44]. This has led to a hypothesis that genes increasing cell proliferation predispose to cancers but protect against T2D, and vice versa inability of -cells to increase cell proliferation predispose to diabetes, and if occurring in other organs, protect against cancer [45]. In general, the risk associated with these variants was modest with Odds ratios in the range of 1.2-1.5. This was only the beginning, an extended meta-analysis of more than 60,000 GWAS data (DIAGRAM) identified variants in or around 6 additional genes (JAZF1, THADA, CDC23, LGR5, ADAMTS9, NOTCH2) [29] with even more modest effect sizes than those seen for the initial variants. A third meta-analysis of even more individuals (> 100,000) is soon to be published. 11 Most of the genetic variants described to date result in impaired -cell function. When we compared high –risk and low-risk genotypes, i.e. those belonging to highest and lowest 20%, high risk genotypes did not influence BMI or insulin sensitivity but they could not increase their -cell function to compensate for the decrease in insulin sensitivity imposed by an increase in BMI [12] (Figure 4, 6). In addition, the GWAS have been extended to quantitative traits like glucose and insulin and have recently identified variants in three genes (G6PC2, GKCR and MTNR1B) to be consistently associated with fasting glucose concentrations [46-48]. KCNQ1: KCNQ1 is an ATP-dependent potassium channel expressed in most tissues. Mutations in the gene cause the long QT- syndrome characterized by severe arrhythmias [49]. Two small (100K chips) Japanese WGAS identified variants in this gene being associated with T2D [50, 51]. We have further replicated these findings in Scandinavian populations and also shown that variants predict future T2D, which partially can be explained by an effect on insulin secretion [52]. The question rose why it was missed in the previous European WGAS. The most likely explanation is that the risk genotype was seen in > 90% of Europeans thereby limiting the power to detect an association. MTNR1B: An intriguing observation was that a common variant in the gene encoding the melatonin receptor 1B (MTNR1B) was associated with impaired insulin secretion, elevated glucose concentrations and increased risk of future T2D (Figure 5) [47]. There is a well-established link between sleep disorders and T2D. Preliminary data suggest that variants in the MTNR1B gene can partially explain this association. We could also show that the MTNR1B gene is expressed in human islets. However, we do not know whether melatonin is produced in islets from serotonin or transported to the islets. The MTNR1B gene was up-regulated in carriers of risk genotypes suggesting a gain-of-function effect increasing risk of T2D. In support of this adding melatonin to clonal -cells inhibited glucose-stimulated insulin secretion (Figure 5). Inhibition of melatonin effects in islets could thus represent a novel therapeutic target. 1.7. Common variants in MODY genes 12 Maturity-onset diabetes of the young (MODY) is an autosomal dominant form of diabetes, where a mutation in a single gene causes the disease. There are at least six forms of MODY caused by mutations in a distinct genes have been found. Most forms of MODY are caused by mutations in different transcription factors, i.e. HNF4 (MODY1), HNF1 (MODY3), IPF-1 (MODY4), HNF1 (MODY5), and NeuroD (MODY6), and only MODY2 caused by mutations in the gene encoded for glucokinase enzyme [53]. Common to all MODY carriers phenotype is that they are characterized by impaired insulin secretion and usually show strong allelic variability, i.e. different mutations cause the disease in different families. We therefore looked at whether common variations in these genes could contribute to common late-onset T2D. This turned out to be the case, and we indeed demonstrated that common variants in HNF1, HNF1 (TCF2) and HNF4 were associated with impaired betacell function [54-56]. It was, however, not easy to detect these subtle effects, which seem to be unmasked in insulin-resistant obese elderly individuals. As mentioned above, the same variants in the HNF1 gene which increases risk of prostate cancer protects against T2D [44]. 1.8. Personalized prediction of T2D risk? Combined information of genetic and clinical risk factors ultimately might aid in personalized prediction of disease risk. Recently we have evaluated effect of clinical and genetic factors to predict progression to diabetes in two prospective cohorts [12]. When we replaced family history with increasing number of T2D associated risk alleles, the risk of T2D gradually increased with increasing number of risk alleles and increasing quartiles of body mass index. The risk was highest in subjects with high genetic risk and highest quartile of BMI yeilding an OR of 8.0 as compared to those with low genetic risk and lowest quartile of BMI (Figure 1). As these studies comprised a large number of participants with long follow-up we were in a unique position to address the question whether genetic risk factors added to clinical risk factors could improve prediction of future diabetes. The results demonstrated that adding genetic markers to the clinical risk factors modestly improved the discriminatory power as assessed by the area under the Receiver Operating Characteristic (ROC) curves (from AUC 0.73 to 0.74) [12]. An important factor defining the discriminative power of clinical and genetic risk factors is duration 13 of follow-up. We also assessed the area under the ROC curves to determine the discriminative ability of clinical and genetic risk factors in relation to quintiles of follow-up time. We observed a decrease in AUC for the clinical model (P=0.01) and an increase in the AUC for the genetic risk score (P=0.01) with increasing duration of follow-up. These findings suggest that an individual genetic profile could be valuable from birth, long before exposure to most environmental risk factors takes place. It has been suggested that using a larger number of common variants can make possible an accurate prediction of genetic risk [57, 58] . Simulation studies have estimated that for an AUC of 0.80 to predict cardiovascular disease it will be necessary to genotype 50 risk variants with allele frequencies of 10% and ORs of 1.5 [59]. However, this figure might look different if we find rare variants with stronger effect size, e.g. with odds ratio > 2-3, possibly requiring about 10 rare variants with strong effect size to explain the genetic risk of T2D. This figure might change completely if biomarkers involved in the key pathway could be identified which together with genetic markers would markedly increase the risk prediction. Taken together, genetic tests cannot be offered yet to predict disease. The main reason is the marginally increased risk associated with each risk variant. However, it may be possible to use them on a population level to reduce the number of individuals needed to be included in trails aiming at prevention of T2D. 1.9. Pharmacogenetics An important goal of genetics is to use the information to improve treatment, i.e. to identify individuals who are more likely than others to respond to a specific therapy. While there are some intriguing examples on the potential of pharmacogenetics for monogenic forms of diabetes [60, 61], its role in the more common forms is still unclear. Patients with neonatal diabetes due to mutations in the KCJN11 gene do much better on treatment with sulfonylureas than with insulin [60]; in fact the sometimes accompanying developmental defects improve. Patients with mutations in glucokinase (MODY 2) can be taken of all treatment including insulin as the disease does not progress and patients with mutations in HNF1 (MODY 3) respond extremely well to sulfonylureas [62]. It has also recently been shown that individuals with the risk genotype in TCF7L2 respond poorly to treatment with sulfonylureas, eventually as a consequence of their more severe impairment in beta-cell function 14 [63]. It is still an open issue whether variants in the TCF7L2 would modify response to incretin mimetics. There is some indication that variants in genes metabolizing/transporting metformin influence its effects [64, 65]. The effect one would like to see is that seen with the rs149056 variant in the gene for SLCO1B1 gene (a cation transporter) for prediction of myopathy during high dose statin therapy; the variant was associated with a 6-fold increased risk of myopathy [66]. Clinical implications and future directions Although it has been debated whether impaired insulin secretion or increased insulin resistance is the key defect in the pathogenesis of T2D, the accumulating evidence today point at the central role of the failing beta cells (Figure 6). Dissecting the genetic architecture of a complex disease such as T2D is a rather challenging task. The genetic variants detected represent common variants shared by a large number of individuals but with modest effects. Each risk allele increases risk of T2D only by 12% [12]. The about 30 T2D genes discovered thus far explain only a small proportion ( 0.3) of the individual risk of T2D (s of 3). It is still possible that there are rare variants with stronger effects not detected with current methods. It is unlikely that high-density DNA arrays can detect these rare variants. Their detection will rather require sequencing. Sequencing of the whole genome was once a dream, but with the new technology this dream may become true in a very near future. Dissection of the genetic complexity of T2D, identifying novel pathways in the pathogenesis of the disease most likely will pave ways to the new therapeutic strategies. 15 Figures legends Figure 1: Risk of incident T2D in individuals with different risk factors. (A) Family history of T2D doubled the risk of T2D associated with a low insulin response to oral glucose. (B) There was an increased risk of T2D with increasing quartiles of BMI and with increasing number of the risk alleles. The risk was highest in subjects with high genetic risk and highest quartile of BMI yeilding an OR of 8.0 as compared to those with low genetic risk and lowest quartile of BMI. The Y axis shows incidence of diabetes. Figure 2: Association of ADRA2A rs553668 with insulin secretion in humans. (A) Effects of rs553668 genotype on insulin levels during IVGTT in 799 individuals. Data are means ± SEM. (B) Immunoblots of total protein from human islets from 8 individuals using polyclonal alpha(2A)AR antisera. The histogram shows average alpha(2A)AR signal normalized for β-actin from 4 blots from a total of 11 GG, 7 GA and 1 AA carriers. (C) Islet ADRA2A mRNA expression in 24 GG, 7 GA and 1 AA carriers. P < 0.05 for GG versus GA/AA, or P < 0.05 for linear regression of expression versus number of risk alleles. (D) Islet insulin secretion at 2.8 or 20 mM glucose with or without alpha(2A)AR antagonist. *P <0.05, **P<0.01, ***P<0.001. Figure 3: Insulin secretion and incretin effect according to different TCF7L2 rs7903146 genotypes. (A) Change in insulin secretion (disposition index) over time in subjects who converted to T2D in the Botnia cohort (risk genotypes = solid line). (B) Risk genotype carriers of the TCF7L2 rs7903146 (risk genotypes = black bars) show impaired incretin effect as shown by lower insulin response to oral than to intravenous glucose. Figure 4: Carriers of high-risk genotypes for T2D (solid line) cannot increase their insulin secretion to compensate for the increase in insulin resistance compared with carriers of low-risk genotypes (dashed line). High and low risk was defined as highest or lowest 20% of risk genotypes. Figure 5: Risk genotype carriers of the MTRN1B gene (black bars and solid lines) show (A) impaired -cell function corrected for insulin sensitivity (disposition effect) 16 cross-sectionally, and (B) decline in beta-cell function over 8-year follow-up period, (C) increased expression of the gene in human islets. (D) Melatonin inhibits glucosestimulated insulin secretion. Figure 6. Schematic view of a potential role of genetic loci influencing risk of T2D and/or glycemic traits in beta-cell function. 17 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Lyssenko V, Almgren P, Anevski D, et al. 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