Carriers of loss-of-function mutations in EXT display impaired pancreatic beta-cell reserve due to smaller pancreas volume

Abstract

Exotosin (EXT) proteins are involved in the chain elongation step of heparan sulfate (HS) biosynthesis, which is intricately involved in organ development. Loss of function mutations (LOF) in EXT1 and EXT2 result in hereditary exostoses (HME). Interestingly, HS plays a role in pancreas development and beta-cell function, and genetic variations in EXT2 are associated with an increased risk for type 2 diabetes mellitus. We hypothesized that loss of function of EXT1 or EXT2 in subjects with hereditary multiple exostoses (HME) affects pancreatic insulin secretion capacity and development. We performed an oral glucose tolerance test (OGTT) followed by hyperglycemic clamps to investigate first-phase glucose-stimulated insulin secretion (GSIS) in HME patients and age and gender matched non-affected relatives. Pancreas volume was assessed with magnetic resonance imaging (MRI). OGTT did not reveal significant differences in glucose disposal, but there was a markedly lower GSIS in HME subjects during hyperglycemic clamp (iAUC HME: 0.72 [0.46-1.16] vs. controls 1.53 [0.69-3.36] nmol·l-1·min-1, p<0.05). Maximal insulin response following arginine challenge was also significantly attenuated (iAUC HME: 7.14 [4.22-10.5] vs. controls 10.2 [7.91-12.70] nmol·l-1·min-1 p<0.05), indicative of an impaired beta-cell reserve. MRI revealed a significantly smaller pancreatic volume in HME subjects (HME: 72.0±15.8 vs. controls 96.5±26.0 cm3 p = 0.04). In conclusion, loss of function of EXT proteins may affect beta-cell mass and insulin secretion capacity in humans, and render subjects at a higher risk of developing type 2 diabetes when exposed to environmental risk factors.

Figure 1. Plasma glucose (A) and insulin curves (B) after OGTT in HME subjects (closed squares) and controls (circles).

Figure 2. Functional (GSIS) pancreas reserve in HME subjects (closed sq) versus controls (circles).

A and B: The first-phase insulin and C-peptide response to a hyperglycaemic clamp was lower in HME subjects compared to controls. C: The glucose infusion rate (GIR), an estimation of the amount of glucose being metabolized, was not different between groups. D and E: Insulin secretion after an intravenous bolus of arginine was lower in carriers vs controls. * p = 0.028.

Figure 3. Pancreas volume, assessed with 3T MRI, was smaller in HME subjects than controls (A) Example of axial (top left), sagital (top right) and coronal (bottom left) view and 3D visualization (bottom right) of delineated pancreas.

(B) Pancreatic volumes (cm³) in HME subjects and controls. # p = 0.04.