Kelainan Genetik

Blok Kesehatan Anak

dr. Zainuri Sabta N

Departemen Anatomi Fakultas Kedokteran UII

Learning objectives
Understand different types of genetic disorder

and how they affect risk of some well characterised diseases Describe the importance of genetics in different diseases (monogenic vs multifactorial)

Organisation of DNA into chromosomes

Number of cells in human body: Starts at 1 Ends up at ~100,000,000,000,000 Divided into ~210 cell types

Requirements during development: 1. Coordination of development 2. Metabolic components 3. Programmed cell death

Gen dan Kromosom

Most autosomal genes are present at 2 copies per cell: one from each parent. Some genes, however, are present at >2 or <2 copies per cell e.g. the copy number of the AMY1 (amylase) gene may vary From Dad from 2 to 15 per cell.

A B

a b

Homologs
C c

D
From Mom

AA Genotypic Aa
A B a b

aa

Homologs
C
From Dad

A Population variation Allelic a

From Mom

Hair colour Phenotypic Weight Blood pressure

Chromosom
Kromosom manusia dibedakan dalam 2 tipe, yaitu Autosom* dan Kromosom seks**. Dari 46 kromoson didalam inti sel tubuh manusia , maka 44 buah atau 22 pasang merupakan autosom, dan sepasang seks kromoson dibedakan atas 2 macam yaitu Kromosom X dan Kromosom Y.
Perempuan homogametic (XX) Laki-laki heterogametic (XY)
*Kromosom yang tidak hubungan dengan penetuan jenis kelamin **Sepasang kromosom yang menentukan jenis kelamin

Genetic Variation can contribute to Genetic Diseases at different levels Chromosomal Single gene defects Polygenic (multifactorial)

Chromosome disorders
Disebabkan oleh kelebihan atau kekurangan gen-gen yang terletak di dalam kromosom atau terjadi perubahan struktur dari kromosom itu sendiri . Misal: Sindrom Down

Monogenic disease (Mendelian)

Multifactorial disease (Complex)

Often rare Distinct mode of inheritance High penetrance Limited environmental influences Disease due to a single gene defect, although other genes may alter severity. Different individuals may have different mutations Examples: Marfan syndrome (fibrillin-1 gene) Duchenne muscular dystrophy (dystrophin gene)

Often common Different individuals may have different mutations No distinct mode of inheritance Low penetrance Important environmental contributing factors Multiple interacting loci, all with small effects Examples: Hypertension Obesity

Different disease aetiologies: multifactorial and monogenic

For some diseases most individuals have a

multifactorial form of the disease, but a small subset of individuals may have a strong (monogenic) genetic component. Examples: breast cancer, colon cancer, hypercholesterolemia 5% of breast cancer cases have a strong genetic component, due to mutations in key genes. Manifest as early age of onset, large familial relative risk.

Genetic models for common disease

Common disease rare variant Many mutations in same or different genes Population risk is low Confer large increase in risk among susceptible individuals Testing is difficult and expensive, but informative Common disease common variant Single variant present in population at high frequency Population risk is high Small increase in risk among susceptible individuals Predictive value of screening is often small

Common disease - rare variant

Example Breast Cancer
5% of cases inherit a mutation in one of two genes:

BRCA1 or BRCA2. Women carrying mutations in either of these genes have an approximately 80% chance of developing breast cancer by age 70. There are so many different mutations in BRCA1 and BRCA2 that each one is almost family specific, which makes population screening difficult.

Common disease - common variant

Example Age-related macular degeneration
The leading cause of untreatable blindness among the

elderly in Western populations. Polymorphism in the complement factor H gene is strongly associated with risk. Relative frequency of the allele which increases risk is 0.34 in the general population. RR among heterozygotes = 2.44 (2.08-2.83) * RR among homozygotes = 5.93 (4.33-8.02) * Population risk is high

* Zareparsi et al, 2005 Am. J. Hum. Genet

Chromosomal Disorders

Caused by the loss or gain of a single chromosome or part of a chromosome The loss or gain of whole chromosomes is often incompatible with life. The most common trisomy is trisomy 21 Downs syndrome

Idealised normal karyotypes

Nondisjunction of chromosomes

Chromosomal disorders - Karyotyping

Normal metaphase Normal male karyotype

Downs Syndrome 47,XX,+21

46,XY

Some abnormalities resulting from nondisjunction

Trisomy

Downs syndrome- extra chromosome 21 (1/650) Pataus syndrome- extra chromosome 13 (1/5000) severe effects; extreme mental retardation, deafness, hare lip, cleft palate, malformations in most organs Edwards syndrome-extra chromosome 18 (1/3000) Skull elongation, low set ears, receding chin, webbed neck, dislocation of hips

Image: Talking Glossary of Genetics, National Human Genome Research Institute (NHGRI). http://www.genome.gov/glossary.cfm. All of the illustrations in the Talking Glossary of Genetics are freely available and may be used without special permission.

Trisomy
Faktor umur ketika melahirkan juga berpengaruh, misalnya pada Kasus Sindroma Down trisomi 21, biasanya lahir sebagai anak terakhir keluarga besar, atau dari usia ibu yang lanjut, nondisjunction terjadi pada meiosis I menghasilkan ovum yang mengandung 2 buah autosom nomor 21 dan bila ovum ini dibuahi oleh sperma normal yang membawa nomor 21 maka terbentuklah zigot trisomi 21

Sex chromosome abnormalities

Monosomy
Turners syndrome X0 chromosome (no Y) 1/3000

Short with webbed neck, poor secondary sexual characteristics, infertility due to absence of ovaries

Trisomy
Klinefelters (XXY) 1/500 males

Infertile due to small testes, tall, slight mental retardation, enlarged breast development

Chromosomal Abnormalities
One chromosome Deletion Duplication Inversion Ring chromosome Isochromosome More than one chromosome

Translocations

Deletions
Mechanisms

Unequal recombination - an error in cross-over during meiosis. Chromosome breaks due to DNA damage (radiation, chemicals etc) and is rejoined incorrectly
Examples

Wolf-Hirschhorn syndrome caused by deletion of tip of 4p Prader-Willi/Angelman syndrome caused by microdeletion of 15p
Image: Talking Glossary of Genetics, National Human Genome Research Institute (NHGRI). http://www.genome.gov/glossary.cfm. All of the illustrations in the Talking Glossary of Genetics are freely available and may be used without special permission.

Translocations
a portion of one chromosome is transferred to another chromosome Chromosome breaks due to DNA damage (radiation, chemicals etc) and material exchanged balanced - equal exchange of material, no genetic information extra or missing unbalanced - unequal exchange of material resulting in extra or missing genes

eg some cancers, especially leukaemias

Image: Talking Glossary of Genetics, National Human Genome Research Institute (NHGRI). http://www.genome.gov/glossary.cfm. All of the illustrations in the Talking Glossary of Genetics are freely available and may be used without special permission.

Other structural abnormalities

Inversion

Chromosome breaks in two places and the intervening sequence is inverted on repair
Insertion

Chromosome breaks in two places and additional material is inserted on repair

Ring chromosome

Both ends of chromosome are lost and ends join to form ring on repair

Occurrence of chromosomal abnormalities

Constitutional

Present in all cells of the body Present early in development sperm or egg abnormal fertilization
Somatic/acquired abnormality

Present only in certain cells or tissues

Mosaic cells with different chromosomal content

Increased risk of common diseases in children with DS

Leukaemia Autoimmunity Alzheimers disease

(Amyloid precursor protein)

Fragile X Syndrome
Males outnumber females by about 25% in institutions for the mentally retarded. In some of these males, the X chromosome is nearly broken, leaving the tip hanging by a flimsy thread. These males are said to have fragile X syndrome Fragile X syndrome occurs in one in 1,000 male births and one in 2,500 female births. As children, fragile X syndrome individuals appear to be normal except they may behyperactive or autistic. Their speech is delayed in development and is often repetitive in nature. As adults, they are short in stature with a long face. The jaw is prominent, and there are big, usually protruding ears Malesalso have large testicles. Stubby hands, lax joints, and a heart defect may also be seen. The symptoms, including mental retardation, are not as severe in females.

Cri du Chat Syndrome

A chromosomal deletion is responsible for cri du chat (cats cry) syndrome, which has a frequency of one in 50,000 live births (Fig. 19.12). An infant with this syndrome has a moon face, a small head, and a cry that sounds like the meow of a cat because of a malformed larynx. An older child has an eyelid fold and misshapen ears that are placed low on the head. Severe mental retardation becomes evident as the child matures. Akaryotype shows that a portion of one chromosome 5 is missing (deleted), while the other chromosome 5 is normal, as are all the other chromosomes.

Sex Chromosomal Inheritance

Too Many/Too Few Sex Chromosomes
Individuals sometimes are born with the sex chromosomes XO (Turner syndrome), XXY (Klinefelter syndrome), XXX (poly-X syndrome), and XYY (Jacob syndrome). No matter how many X chromosomes there are, an individual with a Y chromosome develops into a male.

Normal

Abnormal sex chromosomal inheritance. a. Female with Turner (XO) syndrome, which includes a web neck, short stature, and immature sexual features. b. A male with Klinefelter (XXY) syndrome, which is marked by small testes and breast development in some cases.

Table 3 - Syndromes Associated with Aneuploidy of the Sex Chromosomes

Karyotype Syndrome Frequency Description

45,X (XO)

Turner syndrome

1/5000 female live births

Phenotypic female, gonadal dysgenesis and sexual immaturity after puberty, infertility

XXY

Klinefelters syndrome

1/1000 male live births

Phenotypic male, gonadal dysgenesis and sexual immaturity after puberty, infertility

XYY (XXYY)

XYY syndrome

1/1000 male live births

Phenotypic male, behavioral abnormalities

Single Gene Disorders

Caused by altered expression of a single gene through mutation of coding or regulatory regions
Familial hypercholesterolemia affects 1:500 individuals

Familial breast cancer affects 1:300 individuals

Hereditary colon cancer affects 1:300 individuals

Sickle Cell anaemia affects 1:400 African Americans Cystic fibrosis affects 1:2000 Caucasians

Single Gene Disorders are inherited in Mendelian fashion

I II

~50% are autosomal dominant

One copy of the mutation required (Huntingtons Disease) ~36% are autosomal recessive Mutations in both the paternal and maternal genes required (Cystic fibrosis) ~10% are X-linked (Fragile X)

III

IV

X linked inheritance

Single Gene Disorders

Parents
A A a

AA

Aa

Aa

aa

Tay-Sachs Disease
Occurs predominately in children of Eastern European Jewish ancestry Fatal Disease - death usually occurs before age 4 Autosomal recessive inheritance Degenerative brain disease

Caused by absence of hexosainidase A from body tissue

Symptoms: progressive lethargy in previously healthy 2-6 months old

infants, loss of milestones, visual acuity, seizures, hyper-reflexia, posturing, malnutrition, dysphagia
Diagnosis: Classic cherry red spot on macula, enzyme measurement in

serum, amniotic fluid, white cells

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Sickle Cell Disease

PATHOLOGY

Photo Source: Del Mar Image Library; Used with permission

Normal RBC has a flexible, round shape RBC w/HbS has a normal shape until its O2 delivered to

tissue, then sickle shape occurs Stiff, non-pliable cant flow freely Trapped in small vessels = causes vaso-occlusions, tissue ischemia and infarctions painful episodes, most common area is joints Hemolysis of RBC- lifespan down to 20 days Compensatory mechanism is increased reticulocytes

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Sex-Linkage
Sex-linked traits are defined by genes on the the X

chromosome. (Until recently it was thought Y had no genes) Because sex-linkage really refers to X-linkage, females can be heterozygous for sex-linked traits Can mask the presence of a recessive gene. Often recessives are undesired. Hence, the ominous-sounding term carrier female. In contrast, males directly express whatever alleles are on their X chromosomes. Both dominant or recessive sex-linked traits are expressed, because males are heterogametic, or hemizygous, having only one X chromosome.

Biology, Sixth Edition

Sex Linkage (X-linked) Traits

X
A

X
Such traits are controlled by X-linked a genes Hemophilia Xh Color blindness Xb Some sex-associated traits are autosomal Male-pattern baldness X-linked color blindness

X A

Y
No a locus

Male

Female

Color Blindness

Biology, Sixth Edition

Autosomal Dominant:Huntingtonsdisease
A degenerative neurological disease that leads to dementia.

Affects 1:15,000 individuals ~ 30,000 Americans have HD and ~ 150,000 more are at risk of inheriting the disease from a parent.

Huntingtons disease II
The HD gene mapped to chromosome 4 in 1983 and cloned in 1993. Codes for the protein Huntingtin. The mutation expansion of a nucleotide triplet repeat (CAG) in the DNA at the 5 end of the coding sequence. As the number of repeated triplets - CAG gets larger the Huntingtin gene becomes non-functional <27 CAG (Guanine residues) General population >36 CAG (Guanine residues) HD Anticipation >28 CAG are unstable during replication and this instability increases with the number of repeats. This results genetic anticipation where the age-at-onset of HD gets earlier in successive generations

Autosomal recessive: Cystic fibrosis

gall bladder cystic duct becomes fibrotic (invaded by fibrous tissue)

Skin is salty (usually the first sign).

Diagnosed by sweat test (sensitive and specific)
common bile duct

Thick, sticky mucous covers the respiratory tract and digestive tract.
Respiratory infections.

small intestine

Until recently, patients rarely survived childhood.

CF is caused by a defective gene on chromosome 7, which codes for a sodium chloride transporter CFTR (Cystic fibrosis transmembrane conductance regulator) The gene was cloned in 1989 and the underlying mutations have been well characterised

alternatively spliced exons

6a,b 14a,b 17a,b

250 kb in length 27 exons, 1480 amino acids = 4440 nt coding region (only 2% of the gene!)

The Mutations underlying CF

CF gene CFTR has 3-bp deletion leading to Del508 (Phe) in 1480 aa protein (epithelial Cl- channel) this mutation is found on ~ 70% of CF chromosomes the protein is degraded in the Endoplasmatic Reticulum (ER) instead of being inserted into cell membrane

Heterozygote Advantage
Mutant allele has a high frequency despite reduced fitness of affected individual Heterozygote has increased fitness over both homozygous genotypes

e.g. Sickle Cell Anaemia in West Africa AA Aa aa Normal Susceptible to malaria Carrier Resistant to malaria, anaemia is rare Sickle cell disease severe anaemia

X linked: Fragile X syndrome

Dominant X-linked Severe learning difficulties

More severe in males than in females

Expanding repeat mutation

Genetic variants
Single Nucleotide Polymorphism (SNP): sequence variations that

occur when a single nucleotide in the genome sequence is altered. For a variation to be considered a SNP, it must occur in at least 1% of the population. SNPs, which make up about 90% of all human genetic variation, occur every 100 to 300 bases along the 3-billion-base human genome. Many SNPs have no effect on cell function, but could predispose to disease or influence responses to drugs.
VNTR (Variable number tandem repeats) a short nucleotide sequence

organized as a tandem repeat with different lengths of repeats occurring in different individuals.

Copy Number Variants: gains and losses of large chunks of DNA

sequence consisting of between ten thousand and five million base

Polygenic or Multifactorial diseases

Results from the interaction of multiple genetic variants (some of which have major effects but many have minor effects) and the environment
Most common and least understood of genetic diseases Diabetes (type 1 and type 2) Hypertension Coronary heart disease Schizophrenia Asthma Autisme autoimmune diseases such as multiple sclerosis cancers cleft palate inflammatory bowel disease Obesity

Evidence that a disease is multifactorial

Concordance rates between monozygotic and dizygotic twins Frequency of disease in first and second degree relatives of the proband Migratory studies (type 1 diabetes)

Type 1 Diabetes
Also known as IDDM A paradigm for multifactorial diseases Geographical differences in incidence Affects 0.4% of the population Mean age of onset of 12 years Characterised by autoimmune destruction of insulin producing beta cells - insulin deficiency The risk to a first degree sibling is 10x the population risk

Natural History of Type 1 Diabetes

PUTATIVE ENVIRONMENTAL TRIGGER
CELLULAR AUTOIMMUNITY

BETA CELL MASS

HUMORAL AUTOANTIBODIES LOSS OF FIRST PHASE INSULIN RESPONSE

GENETIC PREDISPOSITION INSULITIS BETA CELL INJURY PREDIABETES DIABETES

GLUCOSE INTOLERANCE

Time

The State of the Nation

Stroke
2-fold increase in obese men and women

obese

desirable BMI

Type 2 diabetes
90% of type 2 diabetic patients have BMI>23

23.6%

27.2% Heart disease and high blood pressure

85% of hypertension is associated with a BMI>25

49.2%

Cancer
10% of all cancer deaths among non-smokers are related to obesity

overweight

Understand obesity, so we can alleviate problems associated with it.

Body Mass Index BMI = weight [kg]/height [m]2

What to do?

Lifestyle: healthy diet & exercise

BUT. Why do 2 people eating the same amount of food not put on the same amount of weight?

Obesity - is it in our genes?

Twin studies: Monozygous twins
(identical DNA/genes)

Genes vs Environment
- brought up together - brought up apart - brought up together - brought up apart
BMI very similar BMI very similar

Siblings
(similar DNA/genes)

BMI a little more similar BMI not similar

But what are those genes and pathways that regulate body weight?

Apa yang berperan dalam varian?

SNP Single Nucleotide Polymorphism
variant nucleotide at a particular position in a DNA

sequence
e.g. in the sequence AACGTACAG (sense)

TTGCATGTC (antisense) AACGCACAG (sense) TTGCGTGTC (antisense)

the middle pair of bases constitutes a SNP

SNPs
Single base substitution: Silent no change of amino acid e.g. TTA to TTG Leu Leu

To qualify as a SNP, the variant must occur in at least 1% of the population

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SNPs
Occur atroughly 1 per 100-300 nucleotides = potentially 10 million SNPs per person

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SNPs
Association studies: - family; case-control; genome-wide Haplotype Set of SNPs on a single chromosome that are statistically associated i.e. are not independent of each other. Tag SNP identifies genetic variation without having to genotype every SNP in a chromosomal region i.e. proxy for set of SNPs.

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Indels

1. 2.

Up to of all human polymorphisms. Five major classes:Single bp insertions or deletions ~ 30% Single bp expansions Expansions of 2 15 bp repeat units Transposon insertions < 1% Insertions of apparently random DNA seqs ~ 40%

3.
4. 5.

About 1/3 of indels are located within known genes.

Indels
Exonic indels which are multiples of three bp will cause insertion or deletion of amino acids. Exonic indels which are not multiples of 3 will cause frameshifts, coding wrong amino acids downstream of the indel, and premature termination of the protein:

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Indels
Disease Deletion of 3 nucleotides causes loss of phenylalanine (F508) in CFTR gene - cystic fibrosis ~ 70% cases

Triplet repeat expansions - fragile X syndrome (>200 CGG) - Huntingtons disease (>36 CAG)
Transposon insertions haemophilia; Duchenne muscular dystrophy; SCID; porphyria; some cancers e.g. leukaemia
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GENETIC TESTING
Test look for alteration in persons gene or

changes in level of key proteins coded for, by specific genes. Abnormal results on these tests could mean that person has an inherited disorders.
1. 2. 3.

Types of genetic tests: Gene tests Chromosomal tests Biochemical tests

Gene test
Gene test looks for signs of disorder in DNA

taken from a persons blood, body fluids, or tissues. Test looks for large changes or small changes. Eg. Huntingtons disease, a person have advance warning of onset of disease. Technique involves using DNA strand known as probe. Other technique involves side by side comparison of healthy persons genes/DNA with the defected one.

Chromosomal test
This test looks at features like-

Chromosome structure, number and arrangement.

Biochemical test
Tests look - Level of key protein.

It signals -Genes that are not working normally.

These types of tests are used for new born

screening. e.g. This screening can detect infants who have metabolic conditions such as Phenylketonuria.

Why do we need genetic testing?

Diagnostic testing

Predictive testing
Presymptomatic testing Carrier testing Prenatal testing Newborn screening Pharmacogenetic testing

Genetic screening
Genetic screening is used to determine

whether a couple is at increased risk of having a baby with a hereditary genetic disorder. Involves assessing the couple's family history. Symptoms of a particular disorder has a gene for that disorder (carrier screening).

Reff
http://learn.genetics.utah.edu/units/disorders/whatare

gd/ http://learn.genetics.utah.edu/units/disorders/ http://www.ornl.gov/sci/techresources/Human_Geno me/medicine/assist.shtml http://www.noah-health.org/en/genetic/

THANK YOU!!!