Introdução: Diabetes Mellitus é a alteração metabólica mais comum na gestação, com prevalência variável de acordo com a população e métodos diagnósticos. Diabetes monogenética ou Diabetes do adulto de início no jovem (Maturity-Onset Diabetes of the Young - MODY) consiste em um subtipo ocasionado por defeito primário na secreção de insulina determinado por herança autossômica dominante, sendo responsável por aproximadamente 1 a 2% dos casos. O diagnóstico genético de gestantes e neonatos acometidos pode propiciar manejo específico, possibilitando melhor prognóstico evolutivo da doença em curto e longo prazo. Objetivos: Analisar alterações moleculares do gene GCK em gestantes com diagnóstico de Diabetes Mellitus e seus neonatos. Metodologia: Estudo transversal, com amostragem consecutiva, sendo incluídas gestantes diabéticas em seguimento no Ambulatório de Endocrinopatias em Obstetrícia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, no período de agosto de 2013 a dezembro de 2015. Amostras sanguíneas maternas e de cordão umbilical foram colhidas no momento do parto e enviadas para extração de DNA e reação em cadeia de polimerase (PCR) para identificação de alterações moleculares no gene GCK. Resultados: Foram encontrados duas mutações que geraram dois polimorfismos no gene da glucoquinase, respectivamente em 13 e em sete pacientes; e uma mutação deletéria que cursou com diagnóstico de MODY GCK em dois pacientes (uma amostra materna e uma de neonato), totalizando alterações em 10,6% dos pacientes. Este diagnóstico permitirá intervenções profiláticas e terapêuticas, interferindo beneficamente na evolução natural da doença. / ntroduction: Diabetes mellitus is the most common metabolic disorder in pregnancy, with prevalence varying according to the population and diagnostic methods. Monogenetic diabetes or Maturity - Onset Diabetes of the Young (MODY) consists of a subtype caused by primary defect in insulin secretion, which is determined by autosomal dominant inheritance and it is responsible for approximately 1-2 % of cases. Genetic diagnosis of affected pregnant women and newborns can provide specific management enabling better evolutionary prognosis of the disease in short and long term. Objectives: To analyze the molecular changes in the GCK gene in pregnant women diagnosed with Diabetes Mellitus and their neonates. Methods: Cross-sectional study with consecutive sampling, that included diabetic pregnant women in follow-up at the Clinical Hospital of the Ribeirão Preto Medical School, University of São Paulo, from August 2014 to December 2015. Maternal and umbilical cord blood samples was collected at time of delivery and sent for DNA extraction and polymerase chain reaction (PCR) to identify molecular changes in the GCK gene. Results: We found mutations that generated two different polymorphisms in the glucokinase gene, one in 13 patients, and the other in seven patients; and a deleterious mutation that was diagnosed with MODY GCK in two patients (a maternal sample and in a neonate), resulting in change in 10,6% of the patients. This diagnosis will determine prophylactic and therapeutic interventions interfering beneficially in the natural evolution of the disease.

Introdução: Diabetes Mellitus é a alteração metabólica mais comum na gestação, com prevalência variável de acordo com a população e métodos diagnósticos. Diabetes monogenética ou Diabetes do adulto de início no jovem (Maturity-Onset Diabetes of the Young - MODY) consiste em um subtipo ocasionado por defeito primário na secreção de insulina determinado por herança autossômica dominante, sendo responsável por aproximadamente 1 a 2% dos casos. O diagnóstico genético de gestantes e neonatos acometidos pode propiciar manejo específico, possibilitando melhor prognóstico evolutivo da doença em curto e longo prazo. Objetivos: Analisar alterações moleculares do gene GCK em gestantes com diagnóstico de Diabetes Mellitus e seus neonatos. Metodologia: Estudo transversal, com amostragem consecutiva, sendo incluídas gestantes diabéticas em seguimento no Ambulatório de Endocrinopatias em Obstetrícia do Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, no período de agosto de 2013 a dezembro de 2015. Amostras sanguíneas maternas e de cordão umbilical foram colhidas no momento do parto e enviadas para extração de DNA e reação em cadeia de polimerase (PCR) para identificação de alterações moleculares no gene GCK. Resultados: Foram encontrados duas mutações que geraram dois polimorfismos no gene da glucoquinase, respectivamente em 13 e em sete pacientes; e uma mutação deletéria que cursou com diagnóstico de MODY GCK em dois pacientes (uma amostra materna e uma de neonato), totalizando alterações em 10,6% dos pacientes. Este diagnóstico permitirá intervenções profiláticas e terapêuticas, interferindo beneficamente na evolução natural da doença. / ntroduction: Diabetes mellitus is the most common metabolic disorder in pregnancy, with prevalence varying according to the population and diagnostic methods. Monogenetic diabetes or Maturity - Onset Diabetes of the Young (MODY) consists of a subtype caused by primary defect in insulin secretion, which is determined by autosomal dominant inheritance and it is responsible for approximately 1-2 % of cases. Genetic diagnosis of affected pregnant women and newborns can provide specific management enabling better evolutionary prognosis of the disease in short and long term. Objectives: To analyze the molecular changes in the GCK gene in pregnant women diagnosed with Diabetes Mellitus and their neonates. Methods: Cross-sectional study with consecutive sampling, that included diabetic pregnant women in follow-up at the Clinical Hospital of the Ribeirão Preto Medical School, University of São Paulo, from August 2014 to December 2015. Maternal and umbilical cord blood samples was collected at time of delivery and sent for DNA extraction and polymerase chain reaction (PCR) to identify molecular changes in the GCK gene. Results: We found mutations that generated two different polymorphisms in the glucokinase gene, one in 13 patients, and the other in seven patients; and a deleterious mutation that was diagnosed with MODY GCK in two patients (a maternal sample and in a neonate), resulting in change in 10,6% of the patients. This diagnosis will determine prophylactic and therapeutic interventions interfering beneficially in the natural evolution of the disease.

Made available in DSpace on 2016-08-19T18:16:07Z (GMT). No. of bitstreams: 1 Dissertacao Ana Gregoria.pdf: 3461170 bytes, checksum: 243ffe696e34289efe111c11281cd8e7 (MD5) Previous issue date: 2012-03-16 / Maturity onset diabetes of young 3 (MODY 3) is the most common monogenic autosomal dominant diabetes caused by mutations in the HNF 1A and characterized by a defect in insulin secretion, decreased renal threshold for glucose and sensitivity to sulfonureia. It is often misdiagnosed as DM 1 or DM 2. By this evidence, this study aims to investigate the HNF 1A gene mutations in patients treated at the outpatient clinic of the University Hospital of DM1 UFMA Sao Luis - MA (HUUFMA), characterize epidemiologically the study population, and identify and describe the mutations found in the gene, correlating them with the chronic complications of diabetes that these patients may have. We evaluated by questionnaire 60 patients with a previous diagnosis of DM 1. These, 20 patients were selected for their clinical features suggestive of MODY for molecular analysis of the HNF 1A gene by sequencing technique. Eleven patients were females and nine males with a mean age of 24.35 ± 6.91 years. Twenty five per cent had retinopathy, 55 %, nephropathy, neuropathy 35 % and 15 % ischemic heart disease. Among the gene variations were found 53 mutations, of these, a deletion in the promoter. Of the 52 variations that occurred in exons, 15 were silent. Among the non- silent, there were 29 missense mutations, seven deletions and one nonsense. Of these, 11 mutations were found in the A isoform, two in the AB isoform and 24 in the ABC isoform. Regarding the fields of protein, it was found: one missense mutation in the dimerization domain, nine mutations in the DNA-binding domain and 25 mutations in the transactivation domain. By correlating the types of mutations, their locations in their respective gene or protein domains with typical chronic complications of diabetes, there was no relationship. However, it was observed that patients with frameshift mutations associated with missense mutations in the transactivation domain had a worse metabolic control than patients with missense mutations in the same domain. With these results we conclude that changes in gene HNF 1A are very common among diabetic patients with a typical characteristics of MODY in this sample, suggesting that the MODY 3 can be cause of DM in many of these patients and the type of mutation and its location in the field protein may be associated with metabolic control in these patients. / Maturity onset diabetes of young 3 (MODY 3)é o mais frequente diabetes mellitus (DM) monogênico autossômico dominante causado por mutações no gene HNF 1A e caracterizado por defeito na secreção de insulina, diminuição no limiar renal de glicose e sensibilidade a sulfonureia, na maioria das vezes. Com frequência é diagnosticado erroneamente como DM 1 ou DM 2. Frente a esta evidência este trabalho tem como objetivo a investigação das mutações do gene HNF 1A em pacientes atendidos no ambulatório de DM1 do Hospital Universitário da UFMA São Luís MA (HUUFMA), assim como caracterizar epidemiologicamente a população de estudo, além de identificar e descrever as mutações encontradas no gene, correlacionando-as com as complicações crônicas próprias do DM que estes pacientes possam apresentar. Foram avaliados por meio de questionário 60 pacientes com diagnóstico prévio de DM 1, destes, 20 pacientes foram selecionados por suas características clínicas sugestivas de MODY para análise molecular do gene HNF 1A pela técnica de sequenciamento. Onze pacientes foram do sexo feminino e nove do sexo masculino com uma média de idade de 24,35 ± 6,91 anos. Destes, 25% apresentavam retinopatia, 55%, nefropatia, 35% neuropatia e 15% cardiopatia isquêmica. Dentre as variações gênicas, foram encontradas 53 mutações, destas, uma deleção no promotor. Das 52 variações que ocorreram nos éxons, 15 eram silenciosas. Entre as não-silenciosas, observaram-se 29 missense, sete deleções e uma nonsense. Destas, 11 mutações encontraram-se na isoforma A, duas na isoforma AB e 24 na isoforma ABC. Em relação aos domínios da proteína, verificou-se: uma mutação missense no domínio de dimerização, nove mutações no domínio de ligação do DNA e 25 mutações no domínio de transativação. Ao se correlacionar os tipos de mutações, suas localizações no gene ou em seus respectivos domínios de proteína com as complicações crônicas típicas do DM, não se observou qualquer relação. Contudo, foi observado que pacientes apresentando associação de mutações frameshift com missense no domínio de transativação apresentavam um pior controle metabólico que pacientes com mutações missense no mesmo domínio. Com estes resultados concluímos que alterações no gene HNF 1A são muito frequentes entre os paciente com DM 1 com características típicas de MODY, sugerindo que o MODY 3 possa ser causa do DM de muitos destes pacientes e que o tipo de mutação e sua localização no domínio de proteína pode ter associação com o controle metabólico destes pacientes.

Les souris invalidées pour Hnf1a présentent un diabète sévère avec défaut d’insulino-sécrétion proche du phénotype observé chez les patients MODY3 (Maturity Onset Diabetes of te Young). Les mécanismes moléculaires responsables du diabète lié à la déficience en Hnf1a ne sont pas clairement compris. Dans ce travail, nous avons montré que des souris congéniques présentant la même délétion de Hnf1a dans des fonds génétiques différents présentent des phénotypes radicalement opposés. En effet, la déficience en Hnf1a conduit à un diabète sévère dans la plupart des lignées telles que 129, B6, BALB/c ou AJ (lignées sensibles). Mais à l’inverse, aucun diabète n’est observé chez les souris congéniques des lignées CBA et C3H malgré le défaut d’expression de Hnf1a (lignées résistantes). Les souris sensibles présentent une altération de leurs îlots de Langerhans avec notamment une diminution de taille de ces îlots. A l’inverse les souris résistantes présentent des îlots beta de taille normale malgré la déficience en Hnf1a. Nous avons pu montrer que le ou les variants génétiques présents dans les deux lignées résistantes agissent de façon dominante et, par un balayage du génome, nous avons identifié un locus majeur suppresseur du phénotype diabétique au niveau du chromosome 3. Ce locus majeur contient 11 gènes présentant des variations de SNP non synonymes et il interagit avec cinq autres loci ancillaires au niveau des chromosomes 4, 11 et 18. Notre travail montre finalement que les variations génétiques naturellement présentes dans les lignées de souris de laboratoire peuvent supprimer le phénotype diabétique lié à la déficience en Hnf1a. / Hnf1a-/- mice exhibit a severe diabetes mellitus due to a drastic defect in insulin secretion that closely resembles to the phenotype presented by MODY3 (Maturity Onset Diabetes of the Young type 3) patients. The molecular mechanisms responsible for the diabetes are still poorly understood. Here we show that congenic mice of different genetic backgrounds carrying the same Hnf1a deletion presented with drastically different phenotypes. Hnf1a-deficiency led to severe diabetes when introgressed into 129, B6, BALB/C or A/J genetic backgrounds (sensitive strains). Conversely, when the same null mutation was introgressed into CBA or C3H genetic backgrounds (resistant strains), the diabetic phenotype was suppressed. In sensitive strains, pancreatic islets did not increase in size compared to control animals and on the other hand average islet-size growth was normal in resistant strains. The genetic variations naturally present in these two resistant strains acted in a dominant way and a genome scan analysis led to the identification of a major suppressor locus on chromosome 3 that accounted for more than 60% of the variance of glycemia. The major locus contained 11 genes with non-synonymous SNPs changes and it interacted with 5 additional ancillary loci on chromosomes 4, 11 and 18. Our study demonstrated that the naturally occurring genetic variation present in distinct mouse laboratory strains is able to suppress the phenotype of a monogenic disorder.

HNF1beta est un facteur de transcription homeobox, dont les mutations sont fréquemment rencontrées chez des patients atteints d’anomalies congénitales du rein et du tractus urinaire (Congenital Abnomalities of the Kidney and the Urogenital Tract, CAKUT). HNF1beta est également impliqué dans le diabète de type Maturity Onset Diabetes of the Young 5 (MODY5). Le laboratoire d’accueil a démontré que HNF1beta était impliqué dans un mécanisme épigénétique, le Bookmarking, nécessaire à la réexpression post-mitotique de ses gènes cibles. En particulier, des expériences de vidéo-microscopie ont montré que la partie N-terminale de HNF1beta, contenant le domaine de liaison à l’ADN, en fusion avec la GFP (HNF1beta -GFP) est liée à la chromatine pendant la mitose. L’objectif de ma thèse était de caractériser les modalités biochimiques d’interaction de HNF1beta avec la chromatine mitotique. Nous avons mis en évidence le fait que la capacité de liaison à l’ADN est indispensable à la localisation mitotique de HNF1beta. En effet, la délétion de la troisième hélice alpha de l’homéo-domaine, responsable de l’interaction avec le grand sillon de l’ADN, entraîne la dissociation de la chromatine de HNF1beta pendant la mitose. Nous avons ensuite étudié l’effet de plusieurs mutations identifiées chez des patients MODY sur la localisation mitotique de HNF1beta. Nos résultats ont montré que certaines mutations faux-sens sont capables d’empêcher la fixation de la chromatine mitotique. Parmi ces mutations, certaines manifestent un phénotype dépendant de la température. Par exemple, à une température permissive, inférieure à 30°C, les mutations P256S et C273Y présentent une localisation mitotique normale. En revanche, à 37°C pour P256S et à 39°C pour le mutant C273Y, les protéines sont complètement dissociées, alors que dans toutes ces conditions de température, l’association de la protéine sauvage avec la chromatine mitotique n’est pas affectée. A température permissive (4°C), nous avons montré par retard sur gel (Electophoresis Mobility Shift Assay EMSA) que les mutants lient l’ADN avec un Kd apparent similaire à celui de la protéine sauvage. Par contre, à température restrictive, les mutants présentent des comportements différents. En effet, P256S perd sa capacité de liaison à l’ADN (de façon réversible), tandis que C273Y continue à lier l’ADN avec une affinité similaire à celui de la protéine sauvage. Le caractère thermosensible des mutants de HNF1beta nous a permis d’étudier les modalités de son recrutement sur la chromatine mitotique. Nos résultats ont montré que l’association des protéines à la chromatine mitotique présente une nature très dynamique. En effet, nous avons observé qu’une diminution rapide de température détermine la relocalisation mitotique réversible de la protéine, dans un délai de quelques secondes. Nous avons pu montrer que la relocalisation mitotique de HNF1beta induit par la température était affectée par une déplétion d’énergie, ainsi que par l’action d’un inhibiteur spécifique de l’importine-β (importazole). Nous avons enfin mis en évidence par immuno-précipitation de chromatine (ChIP) que la liaison de HNF1beta à la chromatine mitotique est séquence-spécifique. Nos résultats suggèrent que le recrutement de HNF1beta à la chromatine mitotique est énergie-dépendante, et nécessite le bon fonctionnement du système de transport lié à l’importine-beta. Mes résultats suggèrent que des mutations trouvées chez des patients MODY3 et MODY5 inactivent ou affaiblissent la capacité de HNF1beta de remplir son activité de Bookmarking. / HNF1beta is a POU transcription factor that is frequently mutated in patients that suffer from diabetes and renal cystic dysplasia. This protein has the peculiar ability to bind mitotic chromosomes and behave as a gene bookmarking. Here we show that the capacity of HNF1beta to bind to DNA plays an essential role for mitotic binding. A close homologue, HNF1alpha, shares the ability of HNF1beta to bind to mitotic chromosomes, and several MODY mutations (e.g P256S, V265L and C273Y) affect the ability of the protein to localize to mitotic chromatin. Interestingly, the phenotype induced by these mutations is very rapidly rescued by sudden temperature shifts. Temperature-sensitivity is probably linked to a conformational change that prevents DNA binding ability of P256S and V265L mutants at 37°C. Interestingly, the mitotic relocalization of these mutants induced by temperature shift was sensitive to energy depletion and importazole, suggesting an active mechanism involving the importin-beta system. Interestingly, C273Y mutant exhibited a significantly mitotic dispersion that is not correlated with any DNA or interphase chromatin binding defect, indicating that DNA binding function is necessary but not sufficient to accomplish bookmarking.

The aim of this thesis is to explore the role of common genetic variation, identified through genome-wide association (GWA) studies, in human traits and diseases, using height as a model polygenic trait, type 2 diabetes as a model common polygenic disease, and maturity onset diabetes of the young (MODY) as a model monogenic disease. The wave of the initial GWA studies, such as the Wellcome Trust Case-Control Consortium (WTCCC) study of seven common diseases, substantially increased the number of common variants associated with a range of different multifactorial traits and diseases. The initial excitement, however, seems to have been followed by some disappointment that the identified variants explain a relatively small proportion of the genetic variance of the studied trait, and that only few large effect or causal variants have been identified. Inevitably, this has led to criticism of the GWA studies, mainly that the findings are of limited clinical, or indeed scientific, benefit. Using height as a model, Chapter 2 explores the utility of GWA studies in terms of identifying regions that contain relevant genes, and in answering some general questions about the genetic architecture of highly polygenic traits. Chapter 3 takes this further into a large collaborative study and the largest sample size in a GWA study to date, mainly focusing on demonstrating the biological relevance of the identified variants, even when a large number of associated regions throughout the genome is implicated by these associations. Furthermore, it shows examples of different features of the genetic architecture, such as allelic heterogeneity and pleiotropy. Chapter 4 looks at the predictive value and, therefore, clinical utility, of variants found to associate with type 2 diabetes, a common multifactorial disease that is increasing in prevalence despite known environmental risk factors. This is a disease where knowledge of the genetic risk has potentially substantial clinical relevance. Finally, Chapter 5 approaches the monogenic-polygenic disease bridge in the direction opposite to that approached in the past: most studies have investigated genes mutated in monogenic diseases as candidates for harboring common variants predisposing to related polygenic diseases. This chapter looks at the common type 2 diabetes variants as modifiers of disease onset in patients with a monogenic but clinically heterogeneous disease, maturity onset diabetes of the young (MODY).

O diabetes mellitus tipo MODY (maturity-onset diabetes of the young) é caracterizado por defeito na secreção de insulina, herança autossômica dominante, hiperglicemia de início precoce e anticorpos anti-células beta negativos. Até o momento, já foram descritas mutações em 14 genes diferentes. A confirmação do diagnóstico de MODY é feita por estudo genético-molecular, tradicionalmente pelo método de Sanger. Diante da grande heterogeneidade genética de MODY, acrescida da dificuldade de estudo de alguns genes por seu grande tamanho e ausência de hotspots, o sequenciamento em larga escala (SLE) mostra-se promissor para uma análise genética custo-efetiva na suspeita de MODY. No Brasil, existem poucos estudos genéticos de rastreamento de MODY e uma alta prevalência de casos sem mutações identificadas nos genes testados (MODY X). Os objetivos deste estudo foram: 1) analisar simultaneamente todos os genes associados a MODY em uma coorte de pacientes com suspeita clínica, utilizando um painel de SLE; 2) avaliar a patogenicidade das variantes alélicas identificadas de acordo com os critérios da Sociedade Americana de Genética Médica (ACMG). Foram selecionados 80 casos com fenótipo de MODY e análise prévia negativa dos 2 genes mais prevalentes, GCK e HNF1A, pelo método de sequenciamento de Sanger. Estes casos foram analisados pelo método de SLE, direcionado para regiões gênicas alvo, por meio de um painel customizado, com sequenciamento simultâneo de 51 genes nucleares e do genoma mitocondrial. As mutações identificadas foram correlacionadas com o fenótipo e foi realizada a segregação familiar. Uma cobertura de no mínimo 20x foi obtida em 98% das regiões alvo. Dos 80 pacientes avaliados, foram detectadas variantes patogênicas/potencialmente patogênicas em 16 casos (20%), confirmando o diagnóstico genético de MODY. Em 15 dos 80 pacientes foram identificadas 16 variantes de significado incerto, restando ainda 42 casos com diagnóstico molecular não esclarecido. Dos 16 casos confirmados geneticamente: 6 foram no gene GCK, 1 no HNF1A, 1 no HNF4A, 1 no HNF1B, 6 em genes raros associados a MODY (1 no ABCC8, 1 no KCNJ11, 1 no PDX1, 2 no PAX4, 1 no NEUROD1), e 1 no NEUROG3, gene associado a diabetes neonatal. Dentre estas 16 variantes, 2 não haviam sido descritas previamente. As 6 mutações no GCK não tinham sido detectadas na análise prévia por: a) 4 casos falso negativos no sequenciamento por Sanger (3 devido ao fenômeno genético de allelic dropout e 1 por erro na leitura do eletroferograma); b) 2 erros na hipótese clínica inicial do subtipo de MODY (baseada no padrão glicêmico e na resposta terapêutica dos pacientes), levando ao sequenciamento prévio de outro gene. A variante no HNF1A não foi detectada previamente por erro na leitura do eletroferograma (caso falso negativo no Sanger). Uma variante foi identificada no gene HNF4A, que não tinha sido sequenciado anteriormente e apresenta fenótipo semelhante ao do HNF1A. O paciente com variante no HNF1B não apresentava relato prévio de cistos renais ou malformações genito-urinárias e por isso não tinha sido considerada a hipótese clínica de MODY5. Além disso, o SLE confirmou o diagnóstico genético de 6 pacientes com variantes em genes de MODY considerados raros, que habitualmente não são sequenciados na rotina de Sanger e ainda detectou uma variante em um gene de diabetes neonatal (sendo necessário maiores estudos para estabelecer uma relação causal com MODY). Em 13 dos 16 casos índices diagnosticados, os familiares encontravam-se disponíveis para exame genético e a co-segregação foi concordante em 8 famílias. Todos os probandos avaliados apresentavam características clínico-laboratoriais típicas de MODY. Os achados deste estudo mostraram que o SLE foi capaz de aumentar a acurácia no diagnóstico de MODY, permitindo a confirmação molecular de 20% dos casos antes negativos e reduzindo, assim, o número de casos MODY X no Brasil. A abordagem genética por painel de SLE para diagnosticar casos com suspeita clínica de MODY mostrou-se promissora para elucidar as bases genéticas desse tipo de diabetes monogênico / Diabetes mellitus type MODY (maturity-onset diabetes of the young) is characterized by defects in insulin secretion, autosomal dominant inheritance, early onset of hyperglycemia, and negative anti-beta cell antibodies. To date, mutations in 14 genes are associated with MODY. The definitive diagnosis relies on genetic tests, traditionally by Sanger sequencing. However, given the genetic heterogeneity of this condition, added to the difficulty of studying some genes due to their large size and lack of hotspots, large-scale sequencing (LSS) seems promising for cost-effective genetic analysis on suspicion of MODY. In Brazil, there are few cohorts screened for MODY and a high prevalence of MODY X (unclear genetic diagnosis). This study aimed to analyze simultaneously all MODY genes in a cohort of clinically suspected patients using a LSS panel; and to evaluate the pathogenicity of identified allelic variants according to the criteria of the American College of Medical Genetics and Genomics (ACMG). We selected 80 subjects with MODY phenotype and negative previous analysis of the 2 most prevalent genes, GCK and HNF1A, by Sanger sequencing method. These cases were analyzed by LSS method, with simultaneous sequencing of target genes. We designed a customized panel, including 51 nuclear genes and the mitochondrial genome. The identified mutations were correlated to the phenotype and family segregation was evaluated. At least 20x coverage was obtained in 98% of the targeted regions. Of 80 evaluated subjects, pathogenic/probably pathogenic variants were detected in 16 cases (20%), confirming the genetic diagnosis of MODY. In 15 of 80 patients, 16 variants of uncertain significance were identified, remaining 42 cases with unexplained molecular diagnosis. Of the 16 genetically confirmed cases: 6 were in the GCK gene, 1 in HNF1A, 1 in HNF4A, 1 in HNF1B, and 6 in rare genes associated with MODY (1 in ABCC8, 1 in KCNJ11, 1 in PDX1, 2 in PAX4 and 1 in NEUROD1), and 1 in NEUROG3, a gene associated with neonatal diabetes. Of these 16 variants, 2 had not been previously described. Those 6 variants in GCK were not detected in the prior analysis because of: a) 4 false negative cases in Sanger sequencing (allelic dropout had occurred in 3 cases and one variant was overlooked, due to electropherogram interpretation failure); b) 2 errors in the initial clinical hypothesis of the MODY subtype (based on the glycemic pattern and therapeutic response), leading to the prior sequencing of another gene. The variant in HNF1A was not previously identified due to misinterpretation in electropherogram (Sanger false negative case). One variant were detected in the HNF4A gene, not formerly sequenced, and had a similar phenotype to that of HNF1A. The patient with HNF1B variant did not have a previous report of renal cysts or genito-urinary malformations and therefore the clinical hypothesis of MODY5 was not considered. In addition, LSS confirmed the genetic diagnosis of 6 patients harboring variants in MODY genes considered to be rare, which are not usually sequenced in the Sanger routine, and also detected one variant in a neonatal diabetes gene (further studies are necessary to establish a causal relationship with MODY). Relatives were available for genetic testing in 13 of these 16 index cases diagnosed and co-segregation was concordant in 8 families. All probands evaluated showed typical clinical and laboratory characteristics of MODY. These study findings showed that targeted-LSS could increase accuracy in MODY diagnosis, enabling molecular confirmation of 20% of previous negative cases and thus reducing the number of MODY X cases in Brazil. The genetic approach of LSS panel to diagnose cases with clinical suspicion of MODY has shown promise for elucidating the genetic basis of this type of monogenic diabetes

O diabetes mellitus tipo MODY (maturity-onset diabetes of the young) é caracterizado por defeito na secreção de insulina, herança autossômica dominante, hiperglicemia de início precoce e anticorpos anti-células beta negativos. Até o momento, já foram descritas mutações em 14 genes diferentes. A confirmação do diagnóstico de MODY é feita por estudo genético-molecular, tradicionalmente pelo método de Sanger. Diante da grande heterogeneidade genética de MODY, acrescida da dificuldade de estudo de alguns genes por seu grande tamanho e ausência de hotspots, o sequenciamento em larga escala (SLE) mostra-se promissor para uma análise genética custo-efetiva na suspeita de MODY. No Brasil, existem poucos estudos genéticos de rastreamento de MODY e uma alta prevalência de casos sem mutações identificadas nos genes testados (MODY X). Os objetivos deste estudo foram: 1) analisar simultaneamente todos os genes associados a MODY em uma coorte de pacientes com suspeita clínica, utilizando um painel de SLE; 2) avaliar a patogenicidade das variantes alélicas identificadas de acordo com os critérios da Sociedade Americana de Genética Médica (ACMG). Foram selecionados 80 casos com fenótipo de MODY e análise prévia negativa dos 2 genes mais prevalentes, GCK e HNF1A, pelo método de sequenciamento de Sanger. Estes casos foram analisados pelo método de SLE, direcionado para regiões gênicas alvo, por meio de um painel customizado, com sequenciamento simultâneo de 51 genes nucleares e do genoma mitocondrial. As mutações identificadas foram correlacionadas com o fenótipo e foi realizada a segregação familiar. Uma cobertura de no mínimo 20x foi obtida em 98% das regiões alvo. Dos 80 pacientes avaliados, foram detectadas variantes patogênicas/potencialmente patogênicas em 16 casos (20%), confirmando o diagnóstico genético de MODY. Em 15 dos 80 pacientes foram identificadas 16 variantes de significado incerto, restando ainda 42 casos com diagnóstico molecular não esclarecido. Dos 16 casos confirmados geneticamente: 6 foram no gene GCK, 1 no HNF1A, 1 no HNF4A, 1 no HNF1B, 6 em genes raros associados a MODY (1 no ABCC8, 1 no KCNJ11, 1 no PDX1, 2 no PAX4, 1 no NEUROD1), e 1 no NEUROG3, gene associado a diabetes neonatal. Dentre estas 16 variantes, 2 não haviam sido descritas previamente. As 6 mutações no GCK não tinham sido detectadas na análise prévia por: a) 4 casos falso negativos no sequenciamento por Sanger (3 devido ao fenômeno genético de allelic dropout e 1 por erro na leitura do eletroferograma); b) 2 erros na hipótese clínica inicial do subtipo de MODY (baseada no padrão glicêmico e na resposta terapêutica dos pacientes), levando ao sequenciamento prévio de outro gene. A variante no HNF1A não foi detectada previamente por erro na leitura do eletroferograma (caso falso negativo no Sanger). Uma variante foi identificada no gene HNF4A, que não tinha sido sequenciado anteriormente e apresenta fenótipo semelhante ao do HNF1A. O paciente com variante no HNF1B não apresentava relato prévio de cistos renais ou malformações genito-urinárias e por isso não tinha sido considerada a hipótese clínica de MODY5. Além disso, o SLE confirmou o diagnóstico genético de 6 pacientes com variantes em genes de MODY considerados raros, que habitualmente não são sequenciados na rotina de Sanger e ainda detectou uma variante em um gene de diabetes neonatal (sendo necessário maiores estudos para estabelecer uma relação causal com MODY). Em 13 dos 16 casos índices diagnosticados, os familiares encontravam-se disponíveis para exame genético e a co-segregação foi concordante em 8 famílias. Todos os probandos avaliados apresentavam características clínico-laboratoriais típicas de MODY. Os achados deste estudo mostraram que o SLE foi capaz de aumentar a acurácia no diagnóstico de MODY, permitindo a confirmação molecular de 20% dos casos antes negativos e reduzindo, assim, o número de casos MODY X no Brasil. A abordagem genética por painel de SLE para diagnosticar casos com suspeita clínica de MODY mostrou-se promissora para elucidar as bases genéticas desse tipo de diabetes monogênico / Diabetes mellitus type MODY (maturity-onset diabetes of the young) is characterized by defects in insulin secretion, autosomal dominant inheritance, early onset of hyperglycemia, and negative anti-beta cell antibodies. To date, mutations in 14 genes are associated with MODY. The definitive diagnosis relies on genetic tests, traditionally by Sanger sequencing. However, given the genetic heterogeneity of this condition, added to the difficulty of studying some genes due to their large size and lack of hotspots, large-scale sequencing (LSS) seems promising for cost-effective genetic analysis on suspicion of MODY. In Brazil, there are few cohorts screened for MODY and a high prevalence of MODY X (unclear genetic diagnosis). This study aimed to analyze simultaneously all MODY genes in a cohort of clinically suspected patients using a LSS panel; and to evaluate the pathogenicity of identified allelic variants according to the criteria of the American College of Medical Genetics and Genomics (ACMG). We selected 80 subjects with MODY phenotype and negative previous analysis of the 2 most prevalent genes, GCK and HNF1A, by Sanger sequencing method. These cases were analyzed by LSS method, with simultaneous sequencing of target genes. We designed a customized panel, including 51 nuclear genes and the mitochondrial genome. The identified mutations were correlated to the phenotype and family segregation was evaluated. At least 20x coverage was obtained in 98% of the targeted regions. Of 80 evaluated subjects, pathogenic/probably pathogenic variants were detected in 16 cases (20%), confirming the genetic diagnosis of MODY. In 15 of 80 patients, 16 variants of uncertain significance were identified, remaining 42 cases with unexplained molecular diagnosis. Of the 16 genetically confirmed cases: 6 were in the GCK gene, 1 in HNF1A, 1 in HNF4A, 1 in HNF1B, and 6 in rare genes associated with MODY (1 in ABCC8, 1 in KCNJ11, 1 in PDX1, 2 in PAX4 and 1 in NEUROD1), and 1 in NEUROG3, a gene associated with neonatal diabetes. Of these 16 variants, 2 had not been previously described. Those 6 variants in GCK were not detected in the prior analysis because of: a) 4 false negative cases in Sanger sequencing (allelic dropout had occurred in 3 cases and one variant was overlooked, due to electropherogram interpretation failure); b) 2 errors in the initial clinical hypothesis of the MODY subtype (based on the glycemic pattern and therapeutic response), leading to the prior sequencing of another gene. The variant in HNF1A was not previously identified due to misinterpretation in electropherogram (Sanger false negative case). One variant were detected in the HNF4A gene, not formerly sequenced, and had a similar phenotype to that of HNF1A. The patient with HNF1B variant did not have a previous report of renal cysts or genito-urinary malformations and therefore the clinical hypothesis of MODY5 was not considered. In addition, LSS confirmed the genetic diagnosis of 6 patients harboring variants in MODY genes considered to be rare, which are not usually sequenced in the Sanger routine, and also detected one variant in a neonatal diabetes gene (further studies are necessary to establish a causal relationship with MODY). Relatives were available for genetic testing in 13 of these 16 index cases diagnosed and co-segregation was concordant in 8 families. All probands evaluated showed typical clinical and laboratory characteristics of MODY. These study findings showed that targeted-LSS could increase accuracy in MODY diagnosis, enabling molecular confirmation of 20% of previous negative cases and thus reducing the number of MODY X cases in Brazil. The genetic approach of LSS panel to diagnose cases with clinical suspicion of MODY has shown promise for elucidating the genetic basis of this type of monogenic diabetes

Las mutaciones en el factor de transcripción HNF1a son la causa más frecuente de diabetes tipo MODY. HNF1a está implicado en una compleja red transcripcional responsable de la diferenciación y función de la célula beta. El estudio de modelos genéticos deficientes para HNF1a será pues de gran relevancia para la comprensión de las bases moleculares de la diabetes MODY y del programa transcripcional responsable del desarrollo de la célula beta, pero también de manera más general, para estudiar como un activador regula la transcripción. El objetivo de este trabajo de tesis es pues emplear diferentes modelos genéticos para comprender aspectos funcionales de HNF1a en un contexto celular in vivo.En una primera parte, nos planteamos responder dónde, cuándo y cúanto HNF1a es necesario para ejercer su función en la célula beta. Diseñamos un modelo de expresión de HNF1a específico de célula beta e inducible por tetraciclina. El sistema sobreexpresaba HNF1a en células beta, lo que inhibía el ciclo celular e inducía apoptosis reduciendo progresivamente la masa de célula beta que acababa derivando en diabetes. Como la inducción de HNF1a en células beta era heterogénea pudimos comprobar que la función de HNF1a tiene autonomía celular y es rescatable postnatalmente sólo en aquellas células deficientes para HNF1a que reexpresaban HNF1a a niveles casi fisiológicos. Concluyendo, en esta primera parte del proyecto se demostró que HNF1a puede ejercer su función en células beta expresándose sólo en células beta, que esta función no está restringida a un momento determinado del desarrollo embrionario y que es altamente dependiente de los niveles de expresión, puesto que tanto mutaciones en heterocigosidad como la sobreexpresión causan diabetes. Estos resultados tienen importantes implicaciones en el diseño de terapias génicas para la cura de la diabetes MODY y en el desarrollo de protocolos de diferenciación in vitro de células beta para su posterior transplante. Así mismo llama la atención sobre los peligros de sobreexpresar factores de transcripción en células beta.En la segunda parte, nos planteamos cómo regula HNF1a la transcripción. Un nuevo nivel de regulación de la transcripción está emergiendo, el posicionamiento génico en subdominios nucleares en fución de la actividad transcripcional. Por otro lado se sabe que HNF1a induce la acetilación de los promotores de sus genes diana. El objetivo de esta segunda parte es estudiar como HNF1a influye las modificaciones de histona a nivel local de cromatina y el reposicionamiento génico en el espacio nuclear para establecer así la relación entre estos dos niveles de regulación de la transcipción. Mediante el uso de un modelo deficiente para HNF1a, demostramos que HNF1a induce la metilación en H3-Lys4 e impide la metilación en H3-Lys27 de sus genes diana. Así mismo estas modificaciones de histona se distribuyen no aleatoriamente en el espacio nuclear formando subdominios. HNF1a induce el reposicionamiento selectivo de sus loci diana de dominios ricos en H3-trimetil Lys27 a dominios activadores ricos en RNA polimerasa II y H3-dimetil Lys4, en concordancia con los cambios observados localmente. Concluyendo, en esta segunda parte demostramos por primera vez que el posicionamiento génico puede ser dependiente de un activador y que afecta selectivamente al locus diana. También demostramos por primera vez que las modificaciones de histona que regulan la transcripción localmente a nivel de la cromatina también tienen una representación espacial en el núcleo de manera que los genes se posicionan en dominios ricos en determinadas modificaciones de histona en función de su actividad transcripcional. Este trabajo de tesis tiene importantes implicaciones en la comprensión de las bases moleculares de una enfermedad humana y añade nuevas perspectivas al estudio de la función de un activador transcripcional. / Mutations in the transcription factor HNF1a are the major cause of MODY type diabetes. HNF1a is implicated in a complex transcriptional network responsible for beta-cell development and function. The study of genetic models deficient for that activator would not only be useful for understanding the molecular bases of a human disease, but also for the study of the transcriptional network implicated in the differentiation of beta-cells and the study of how transcription is actually regulated.The aim of this project of thesis was to understand the function in vivo of HNF1a in beta-cells using genetic models.In the first part, we aimed to assess when, where and how much HNF1a is needed in the beta-cell to be functional. For that purpose, we used a conditional and cell-specific model that overexpressed HNF1a only in beta-cells and in the absence of tetracycline. We demonstrated that the function of HNF1a in beta-cells is cell-autonomous, can be rescued postnatally and is tightly dependent on its expression levels, since both mutations in heterozygosity and overexpression lead to diabetes. These results have important implications in the development of gene therapies for MODY3 patients and for the establishment of good protocols for beta-cell differentiation in vitro for transplantation. This study also highlights the risk of misexpressing transcriptions factors in beta-cells. In the second part, we aimed to understand how HNF1a regulates transcription using an HNF1a-deficient model. HNF1a induces changes locally at the chromatin level by preventing the methylation of H3-Lys27 and inducing the acetylation and methylation of H3-Lys4 of its targets nucleosomes. HNF1a also induces the repositionning of its target loci from H3-methyl Lys27 rich domains to active RNA polymerase II and H3-methyl Lys4 rich domains in the nuclear space, concordantly with the changes observed locally. Thus, for the first time we show that an activator can locus-selectively determine the subnuclear positioning of its targets and that histone modifications have a functional representation in the nuclear space. This thesis add novel insights to our understanding of the in vivo function of a transcriptional activator, and for the first time link subnuclear gene repositioning to a human transcriptional disease.

This discourse deals with a theoretical study of the radiation passage through a diffraction screen with non-zero size in the propagation direction of the radiation, i.e. the radiation passage through a three-dimensional object. Without any loss of generality, we solve the problem for cylindrical cavity in metal. The task exceeds evidently standard scalar theory of diffraction, thus we solve the problem using a waveguiding theory. Following the principles of the electromagnetic theory, we derive required formulae to determine mode distribution at the entry of the cavity. Further, we solve numerically the radiation propagation through the cavity, then we actually seek for radiation distribution at the very end of the cavity. This yields, with a help of the discrete Fourier transform, an intensity distribution of Fraunhofer diffraction pattern, consequently compared with an intesity distribution of the radiation pattern of Fraunhofer diffraction on infinitely thin circular opening having the radius of the cylinder cavity under study. A comparison of such patterns results to a conclusion, that the cavity length has a significatn influence on the diffraction pattern and more importantly, that the scalar diffraction theory appears incorrect for a coherent light passage through cavities longer than their radius squared. Similarly, the same conclusion is inversely proportional to a wavelength of the interacting radiation. Finally, we mention an existence of the so called "focal regime", when the radiation repeatedly exhibits roughly one order increased intensity on the symmetry axis of the cavity.