title: Extremes of clinical and enzymatic phenotypes in children with hyperinsulinism caused by glucokinase activating mutations.
abstract: OBJECTIVE
  Heterozygous activating mutations of glucokinase have been reported to cause hypoglycemia attributable to hyperinsulinism in a limited number of families. We report three children with de novo glucokinase hyperinsulinism mutations who displayed a spectrum of clinical phenotypes corresponding to marked differences in enzyme kinetics.
  
  
  METHODS
  Mutations were directly sequenced, and mutants were expressed as glutathionyl S-transferase-glucokinase fusion proteins. Kinetic analysis of the enzymes included determinations of stability, activity index, the response to glucokinase activator drug, and the effect of glucokinase regulatory protein.
  
  
  RESULTS
  Child 1 had an ins454A mutation, child 2 a W99L mutation, and child 3 an M197I mutation. Diazoxide treatment was effective in child 3 but ineffective in child 1 and only partially effective in child 2. Expression of the mutant glucokinase ins454A, W99L, and M197I enzymes revealed a continuum of high relative activity indexes in the three children (26, 8.9, and 3.1, respectively; wild type = 1.0). Allosteric responses to inhibition by glucokinase regulatory protein and activation by the drug RO0281675 were impaired by the ins454A but unaffected by the M197I mutation. Estimated thresholds for glucose-stimulated insulin release were more severely reduced by the ins454A than the M197I mutation and intermediate in the W99L mutation (1.1, 3.5, and 2.2 mmol/l, respectively; wild type = 5.0 mmol/l).
  
  
  CONCLUSIONS
  These results confirm the potency of glucokinase as the pancreatic beta-cell glucose sensor, and they demonstrate that responsiveness to diazoxide varies with genotype in glucokinase hyperinsulinism resulting in hypoglycemia, which can be more difficult to control than previously believed.
authors.affiliation: Clinical Translational Research Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
authors.forename: Samir
authors.initials: S
authors.lastname: Sayed
authors.forename: David R
authors.initials: DR
authors.lastname: Langdon
authors.forename: Stella
authors.initials: S
authors.lastname: Odili
authors.forename: Pan
authors.initials: P
authors.lastname: Chen
authors.forename: Carol
authors.initials: C
authors.lastname: Buettger
authors.forename: Alisa B
authors.initials: AB
authors.lastname: Schiffman
authors.forename: Mariko
authors.initials: M
authors.lastname: Suchi
authors.forename: Rebecca
authors.initials: R
authors.lastname: Taub
authors.forename: Joseph
authors.initials: J
authors.lastname: Grimsby
authors.forename: Franz M
authors.initials: FM
authors.lastname: Matschinsky
authors.forename: Charles A
authors.initials: CA
authors.lastname: Stanley