Genetic mutations of hyperlipidaemiaand acute pancreatitis

Wei Huang MD PhDSichuan Provincial Pancreatitis Centre

West China BiobanksIntegrated Traditional Chinese and Western Medicine

West China Hospital of Sichuan UniversityPancreasFest 2019 ・ Pittsburgh

Chengdu Global CenterWorld’s largest single building

Sun Bird- City SignB.C. 1300

Hot PotNo.1 in China

Giant PandaWorld’s largest Base of Giant Panda Breeding

Taikoo Li Chengdu2015 Global Award for Excellence (by Urban Land Institute)

Wu Hou ShrineFamous history site of Three Kingdoms period

Chengdu city

Nature Index 2015

Chengdu science output

Shangjin Campus, 2012, 1170 beds

WCH

Tianfu New Zone Campus,2017-2018, 1500 beds

Leshan Campus, 2019-2020, 2000 beds

Jinjiang Campus, 2018, 1500 beds

Chengdu city

Main Campus,1892, 4300 beds

Omar L. Kilborn

A one-doctor clinicRenji and Cunren Hospital1892

Medical School of West China Union University1914

Wenjiang Campus, 2013, 200 beds

West China Hospital

> 10,000 beds

“Turning quantity into quality”

Pancreatic services in WCH

Pancreatic surgery: circa 1300 cases Necrosectomy: 400 Laparoscopic

pancreaticoduodenectomy: 190 Open pancreaticoduodenectomy: 280

Department of Integrated Traditional Chinese and Western Medicine

(218 beds)

Acupuncture Lung Disease Acute abdomens Anorectal Oncology

Bedsideservice 62 beds 75 beds 57 beds 24 beds

Pharmacology Laboratory of Traditional Chinese

Medicine

Laboratory of Integrated Traditional Chinese and

Western Medicine

Integrated Traditional Chinese and Western Medicine Clinical

Publications in recent 5 years:BMJ, Gut, Am J Gastroenterol, Intensive Care Med, Crit Care Med, Ann Surg, Brit J Surg, Theranostics, J Control Release, Cell Death Dis, Cell Prolif, Acta Pharm Sin B

Metabolic syndrome

Gurka MJ et al. Nutr Diabetes. 2018;8:14Langan SM et al. J Invest Dermatol 2012;132:556-62Li R et al. BMC Public Health 2016;16:296Rampal S et al. PLoS One 2012;7:e46365Nag T et al. Am J Hum Biol 2015;27:724–7SyRG LEJ et al. J Atheroscler Thromb 2014;21:S9–17OguomaVM et al. Public Health 2015;129:413–23de Carvalho VF et al. BMC Public Health 2013;13:1198Gundogan K et al. Arch Med Sci 2013;9:243–53Amirkalali B et al. Iran Red Crescent Med J 2015;17:e24723

Increased prevalence of central obesity and HTG in China

Abdominal obesity

HTG

Crude 7·7 (0·3) 24·8 (0·5)Men 1·7 (0·2) 24·9 (0·7)Women 13·9 (0·5) 24·6 (0·7)LocationNorth 11·0 (0·5) 26·5 (0·7)South 5·5 (0·3) 23·9 (0·6)Urban 10·1 (0·4) 32·3 (0·6)Rural 7·2 (0·3) 23·1 (0·6)

Types Sex No. of study Sample Pooled prevalence(95% CI) (%)

Central obesity Male 14 38,434 33.4 (25.3-41.5)Female 15 44,646 46.1 (37.0-55.2)

Hypertension Male 14 38,434 52.8 (45.3-60.4)Female 15 44,646 40.1 (32.2-48.0)

High FPG Male 14 38,434 31.5 (25.3-37.8)Female 15 44,646 26.3 (19.0-33.6)

HTG Male 14 38,434 32.9 (27.5-38.3)Female 15 44,646 27.7 (22.0-33.4)

Low HDL-C Male 14 38,434 27.4 (22.2-32.5)Female 15 44,646 40.4 (30.6-50.2)

Li R et al. BMC Public Health 2016;16:296Gu D et al. Lancet 2005;365:1398-405

Heterogenous definition for HTG

Carr et al. Pancreatol 2016;16:469-76

Guideline Definition TG levels (mmol/L)

TG levels (mg/dL)

2003 NCEP ATP III

Normal <1.7 <150 Borderline high

1.7–2.3 150–199

High 2.3–5.65 200–499 Very high >5.65 500

2011 ESC/EAS

Normal <1.7 <150 High 1.7–9.9 150-884

Severe ≥10 ≥8852012 Endocrine Society

Normal <1.7 <150 Mild 1.7–2.3 150–199 Moderate 2.3–11.2 200–999 Severe 11.2–22.4 1000–1999 Very severe ≥22.4 ≥2000

NCEP ATP III = National Cholesterol Education Program Adult Treatment Panel III; ESC = European Society of Cardiology; EAS = European Atherosclerosis Society

Berglund et al. J Clin Endocrinol Metab 2012;97:2969-89Hegele RA et al. The Lancet Diabetes & Endocrinol 2014;2:655-666

Classification of HTGPrimary HTG GeneticsFamilial chylomicronaemia (HLP type 1) Monogenic; autosomal recessive due to two mutant alleles of LPL, APOC2, APOA5,

LMF1, GPIHBP1, or GPD1Familial combined hyperlipidaemia (HLP type 2B) Polygenic; high GRS for HTG; excess of rare variants in HTG-associated genes; high

GRS for LDL cholesterolDysbetalipoproteinaemia (type 3) Polygenic; high GRS for HTG; excess of rare variants in HTG-associated genes; APOE

ε2/ε2 homozygosity, or heterozygous rare mutation in APOEPrimary or simple hypertriglyceridaemia (type 4) Polygenic; high GRS for HTG; excess of rare variants in HTG-associated genes

Primary mixed hypertriglyceridaemia (type 5) Polygenic; high GRS for HTG; excess of rare variants in HTG-associated genes, with higher burden of risk alleles than for hyperlipoproteinaemia type 4

Secondary HTGDiet with high positive energy-intake balance, and high fat, high glycaemic index and alcohol excess

Disorders of metabolism disease states: obesity, metabolic syndrome, diabetes (mainly type 2 diabetes), pregnancy (particularly in the third trimester), hypothyroidism, hypercortisolism, paraproteinaemiaOther disease states: Renal disease (nephrotic syndrome, renal failure), liver disease (acute hepatitis), systemic lupus erythematosus

Drugs (estrogen, second generation antipsychotic, antidepressants, isotretinoin, rosiglitazone, steroids, thiazides, beta-blockers, bile acid sequesterants, sirolimus, and antiretroviral therapy)

Hegele RA et al. Lancet Diabetes Endocrinol 2014;2:655-66

Official symbol Function Mutation Phenotypes

Approximate homozygote prevalence

LPL Encoding LPL, which catalyses hydrolysis of TG-

rich lipoproteins

LOF Type 1 HLP,

hyperapobetalipoproteinaemia

1 per million

APOA5 Encoding APOA5, which stabilises the

lipoprotein–LPL complex

LOF Familial HTG, familial type 5 HLP ＜10 families

APOC2 Encoding APOC2, which acts as an essential LPL

activator

LOF Apolipoprotein C2 deficiency ＜20 families

GPIHBP1 Encoding GPIHBP1, which mediates the

transmembrane transport and binding of LPL

LOF type ID HLP ＜5 families

LMF1 Encoding LMF1, which is involved in the folding

and expression of LPL

LOF Lipase deficiency combined ＜5 families

Genetics of HTG

LPL = lipoprotein lipase; TG = triglycerides; LOF = loss of function; APOA5 = apolipoprotein A5; HLP = hyperlipoproteinaemia;APOC2 = apolipoprotein C2; GPIHBP1 = glycosylphosphatidylinositol anchored high density lipoprotein binding protein 1; LMF1 =lipase maturation factor 1

Hegele RA et al. Lancet Diabetes Endocrinol 2014;2:655-66; Khera AV et al. Nat Genet 2018;50:1219-1224

Complex genetic basis for HTG

Polygenic scores vs. monogenic mutations

Liu DJ et al. Nat Genet 2017;49:1758-1766

Protein-altering variants at novel loci

Genetics of pancreatitis

Modified from Mayerle J et al. Gastroenterol 2019; 156:1951-1968.e1951

• PRSS1

• CPA1

• CEL

• …

Trypsin-dependent

pathway

• PRSS1

• PRSS2 (protective)

• SPINK1

• CTRC

• …

• CFTR

• CASR

• CLDN2

• …

Mis-folding–dependent

pathway

Ductal pathways

Gene Mutation Phenotype Mechanism

PRSS1 p.R122C, p.R122H, p.N29I, pA16V, p.P17T, p.D19A, p.D21A, p.D22G, p.K23R, p.K23_I24insIDK

Autosomal dominant HP, familial pancreatitis, or sporadic CP

Trypsin-dependent

p.R116C, p.C139S,p.L104P, p.C139F, p.G208A, p. D100H, p. K92N, p.S124F

Sporadic or familial CP Mis-folding–dependent

c.-204C>A Protection against alcoholic CP Trypsin-dependent

PRSS2 p.G191R Protection against CP Trypsin-dependent

PRSS1-PRSS2 Copy Number Mutations Hereditary pancreatitis, idiopathic CP Trypsin-dependent

SPINK1 p.N34S, c.194þ2T>C Increased susceptibility for CP Trypsin-dependent

CTRC p.A73T, p.K247_R254del, p.R254W, p.V235I, p.G60=

Increased susceptibility for CP Trypsin-dependent

CTRB1-2 Locus inversion Protection against CP Trypsin-dependent

CPA1 p.N256K, p.S282P, p.R382W, p.R27X Sporadic and familial CP Mis-folding–dependentCEL Single-nucleotide deletions MODY8 Mis-folding–dependent

CEL-HYB1 Increased susceptibility for CP Mis-folding–dependentPNLIP p.T221M Increased susceptibility for CP Mis-folding–dependent

CRTR p.F508del, p.R117H Increased susceptibility for CP Ductal

CASR p.R990G, p.A986S, over-representation Increased susceptibility for CP? Ductal

CLDN2 CLDN2–MORC4 variants Increased susceptibility for CP Ductal

Susceptibility genes of pancreatitis

Pathway Gene

Inflammatory response IL-1β, IL-1, IL-1RN, IL-6, IL-8, IL-10, TNF-α, IL-23R, TLRs, CD14, RIPK2, NOD2, CCL2 (encodes MCP1), NFKB1, MIF, TNFAIP3, MBL2 HY/LX, DEFB1, HBDs

Oxidative stress GST family, iNOS, COX-2, HO-1

Apoptosis CASP7, CASP8, CASP9, CASP10, LTA, TNFRSF1B, TP53

Angiogenesis-related VEGFR-2, CXCR-2, PAR-1, EGF, TNF-β

Metabolism and enzyme ACE I/D, VEGFR-2/KDR, VDR, MMP, FXR

Blood system Thalassemia gene, HLA-DQA1–HLA-DRB1

Tight junction PARD3 and MAGI2, MYO9B: myosin IXB

Other Hydroxytryptamine (serotonin) receptor 2C, G protein-coupled (HTR2C), HSP70-2G, fibroblast growth factor receptor 4 (FGFR4)

Modifier genes of pancreatitis

Genetics of HTG and pancreatitis

Yang X et al. 2019 manuscript prepared

Pancreatitis HTG

Other risk factors

Genetics of HTG-AP

• No GWAS

• Case > cohort

• Novel mutation > reported mutation

• HTG risk genes > pancreatitis risk genes

• Gene-environment interaction

• PRSS1

• SPINK1

• CTRC

• CFTR

• LPL

• APOC2

• LMF1

• Alcohol

• Smoking

• Obesity

• Diabetes

• CASR

• CEL

• CPA1

• GPIHBP1

• APOA5

• GPD1

Pancreatitis

HTG

Genotype

Environment Other risk factors

Genotype

Environment Other risk factors

Petrov MS et al. Nat Rev Gastroenterol Hepatol 2019;16:175-184Sankaran SJ et al. Gastroenterol 2015;149:1490-1500.e1491

Yadav D et al. Gastroenterol 2013;144:1252-1261

Complex interactions

Disease continuum

Murphy M et al. JAMA Intern Med2013;173:162-164;Pedersen S et al. JAMA Intern Med2016;176:1834-1842;Wu BU et al. Dig Dis Sci2019;64:890-897

HTG increases risk of AP and RAP

HTG = hypertriglyceridemiaTG = triglycerides

Mukherjee R et al. Precis Clin Med 2019;2(2):81-86

Increased incidence of HTG-APHypertriglyceridemia-associated acute pancreatitis (HTG-AP)Incidence: 0.13 (95% CI: 0.1-0.17)

Baseline characteristics

Totaln=2145

MAPn=958

MSAPn=718

SAPn=469

Age, years* 45 (38-55) 44 (37-53) 45 (38-56) 46 (39-59)Male sex 1420 (66.2) 665 (69.4) 457 (63.6) 298 (63.5)Pre-existing comorbidity

Pulmonary 56 (2.6) 19 (2.0) 19 (2.6) 18 (3.8)Cardiovascular 368 (17.2) 142 (14.8) 115 (16.0) 111 (23.7)Liver 983 (45.8) 466 (48.6) 324 (45.1) 193 (41.5)Diabetes 420 (19.6) 168 (17.5) 161 (22.4) 91 (19.4)

AetiologyBiliary 650 (30.3) 295 (30.8) 228 (31.8) 127 (27.1)Hyperlipidaemic 657 (30.6) 280 (29.2) 206 (28.7) 171 (36.5)Alcohol excess 106 (4.9) 35 (3.7) 42 (5.8) 29 (6.2)Mixed 165 (7.7) 49 (5.1) 59 (8.2) 57 (12.2)Unknown or others 567 (26.4) 299 (31.2) 183 (25.5) 85 (18.1)

Shi N et al. Gut 2019 pii: gutjnl-2019-318241

HTG-associated AP in WCH

Serum TG > 1000 mg/dl is associated with more pancreatic necrosis

Nawaz H et al. Am J Gastroenterol 2015;110:1497–1503

Vipperla K et al. J Clin Gastroenterol 2017; 51: 586-59

HTG increases severity

Persistent respiratory failure 2.88 (1.61, 5.13)

Persistent renal failure 3.18 (1.92, 5.27)

Persistent shock 3.78 (1.69, 8.44)

Mortality 1.90 (1.05, 3.45)Wang Q et al. J Clin Gastroenterol 2017; 51:586-59

Zhang R et al. HPB (Oxford) 2019 pii: S1365-182X(19)30071-1

Zhang R et al. HPB (Oxford) 2019 pii: S1365-182X(19)30071-1

Yang N et al. Gut 2019;68:378-380

HTG retards regeneration

FFAs correlate with severityCE = cholesteryl ester

CER = ceramide

FFA = free fatty acid

HCER = hexosylceramide

LCER = lactosylceramide

LPE = lysophosphatidylethanolamine

PC = phosphatidylcholine

PE = phosphatidylethanolamine

PEO = ether-linked alkyl

phosphatidylethanolamine

PEP = ether-linked alkenyl

phosphatidylethanolamine

SM = sphingomyelin

TAG = triacylglycerol

TAKEN OUT

FFAs induce pancreatic toxicity

Werner J et al. Gastroenterol 1997;113:286-94Criddle DN et al. Gastroenterol 2006;130:781-93Navina S et al. Sci Transl Med 2011;107:107ra110Criddle DN et al. Proc Natl Acad Sci U S A2004;101:10738-43Huang W et al. Gut 2014;63:1313–1324Noel P et al. Gut 2016;65:100-111de Oliveira C et al. Gastroenterol 2019;156:735-747

Summary• HTG is associated with high

risk of AP

• Serum TG levels correlate with severity of AP

• HTG acerbates severity of AP caused by other aetiology

• HTG worsens long-term pancreatic exocrine and endocrine function

• HTG increases risk of RAP and possibly CP?

Unmet treatment! Mukherjee R et al. Precis Clin Med 2019;1:81-86

Acknowledgments• West China Pancreas Centre: Professors Qing Xia, Lihui Deng, Weimin Hu,

Xubao Liu, Yan Kang, Bin Song, Yu Cao and all multiple-disciplinary members

• State Key Laboratory of Biotherapy of Sichuan University: Professors Lu Chen and Xianghui Fu; colleagues from Nanjing, Nanchang and Shanghai

• International collaborators: Professors Robert Sutton (Liverpool), John A. Windsor (Auckland), Vikesh K. Singh (Baltimore), J Enrique Dominguez-Munoz (Santiago de Compostela)

• Invitation from Professor David C. Whitcomb (Pittsburgh) and PancreasFest

• Email address: dr_wei_huang@scu.edn.cn; wetchat: iPancreas