* 600281

HEPATOCYTE NUCLEAR FACTOR 4-ALPHA; HNF4A


Alternative titles; symbols

HNF4-ALPHA
HEPATOCYTE NUCLEAR FACTOR 4; HNF4
TRANSCRIPTION FACTOR 14, HEPATIC NUCLEAR FACTOR; TCF14


HGNC Approved Gene Symbol: HNF4A

Cytogenetic location: 20q13.12     Genomic coordinates (GRCh38): 20:44,355,699-44,434,596 (from NCBI)


Gene-Phenotype Relationships
Location Phenotype Phenotype
MIM number
Inheritance Phenotype
mapping key
20q13.12 {Diabetes mellitus, noninsulin-dependent} 125853 AD 3
Fanconi renotubular syndrome 4, with maturity-onset diabetes of the young 616026 AD 3
MODY, type I 125850 AD 3

TEXT

Description

The hepatocyte nuclear factor-4-alpha (HNF4A) is a member of the nuclear receptor family of transcription factors and is the most abundant DNA-binding protein in the liver, where it regulates genes largely involved in the hepatic gluconeogenic program and lipid metabolism (summary by Chandra et al., 2013).


Cloning and Expression

Cell specificity is based on differential gene expression, which is in turn determined, at least in part, by a particular set of transcription factors present and active in a given cell at a certain time. Isoforms of a transcription factor can be expressed at different stages of cell differentiation. Many transcription factors have been identified and characterized, particularly in the liver where there is a wide range of transcriptionally controlled genes. The extinction of many hepatic functions and their reexpression are correlated with the extinction and expression of hepatocyte nuclear factor-4 (HNF4). Moreover, HNF4 has a key role in a transcriptional hierarchy since it also controls the expression of the transcription factor HNF1 (TCF1; 142410), which is important in the expression of several hepatic genes. Chartier et al. (1994) demonstrated that there are 2 isoforms of HNF4 in human liver, a situation comparable to that in the rat. The 2 isoforms differ by an extra peptide of 10 amino acids located in the C-terminal part of the protein. The gene is also symbolized TCF14.


Gene Structure

Furuta et al. (1997) reported the exon/intron organization and partial sequence of the HNF4A gene. In addition, they screened 12 exons, flanking introns and minimal promoter regions for mutations in a group of 57 unrelated Japanese subjects with early-onset noninsulin-dependent diabetes mellitus (NIDDM; 125853)/maturity-onset diabetes of the young (MODY, see 125850) of unknown cause. They identified an arg127-to-trp mutation (R127W; 600281.0003) in 3 of 5 diabetic members of one family.

Thomas et al. (2001) identified an alternative promoter of the HNF4A gene, P2, which is 46 kb 5-prime to the previously identified P1 promoter of the human gene. Based on RT-PCR, this distant upstream P2 promoter represents the major transcription site in pancreatic beta-cells, and is also used in hepatic cells. Transfection assays with various deletions and mutants of the P2 promoter revealed functional binding sites for HNF1A (142410), HNF1B (189907), and IPF1 (600733), the other transcription factors known to encode MODY genes. In a large MODY family, a mutated IPF1 binding site in the P2 promoter of the HNF4A gene cosegregated with diabetes (lod score 3.25). The authors proposed a regulatory network of the 4 MODY transcription factors interconnected at the distant upstream P2 promoter of the HNF4A gene.


Mapping

Argyrokastritis et al. (1997) used genetic linkage analysis and fluorescence in situ hybridization to map HNF4 to chromosome 20, in a region syntenic with mouse chromosome 2, where the hnf4 homolog had been assigned by Avraham et al. (1992).

Gross (2014) mapped the HNF4A gene to chromosome 20q13.12 based on an alignment of the HNF4A sequence (GenBank BC137539) with the genomic sequence (GRCh38).


Biochemical Features

Crystal Structure

Chandra et al. (2013) described the 2.9-angstrom crystal structure of the multidomain human HNF4-alpha homodimer bound to its DNA response element and coactivator-derived peptides. A convergence zone connects multiple receptor domains in an asymmetric fashion, joining distinct elements from each monomer. An arginine target of PRMT1 (602950) methylation protrudes directly into this convergence zone and sustains its integrity. A serine target of protein kinase C (see 176960) is also responsible for maintaining domain-domain interactions. These posttranslational modifications lead to changes in DNA binding by communicating through the tightly connected surfaces of the quaternary fold. Chandra et al. (2013) found that some mutations resulting in MODY1 (125850), positioned on the ligand-binding domain and hinge regions of the receptor, compromise DNA binding at a distance by communicating through the interjunctional surfaces of the complex. The overall domain representation of the HNF4-alpha homodimer is different from that of the PPAR-gamma (601487)-RXR-alpha (180245) heterodimer, even when both nuclear receptor complexes are assembled on the same DNA element.


Gene Function

Tirona et al. (2003) showed that HNF4A is critically involved in the PXR (603065)- and CAR (603881)-mediated transcriptional activation of CYP3A4 (124010). They identified a specific cis-acting element in the CYP3A4 gene enhancer that confers HNF4-alpha binding and thereby permits PXR- and CAR-mediated gene activation. Fetal mice with conditional deletion of Hnf4-alpha had reduced or absent expression of CYP3A. Furthermore, adult mice with conditional hepatic deletion of the gene had reduced basal and inducible expression of CYP3A. These data identified HNF4-alpha as an important regulator of coordinate nuclear receptor-mediated response to xenobiotics. To elucidate how differentiated cells form tissues and organs, Parviz et al. (2003) studied liver organogenesis because the cell and tissue architecture of this organ is well defined. Approximately 60% of the adult liver consists of hepatocytes that are arranged as single-cell anastomosing plates extending from the portal region of the liver lobule toward the central vein. The basal surface of the hepatocytes is separated from adjacent sinusoidal endothelial cells by the space of Disse, where the exchange of substances between serum and hepatocytes takes place. The apical surface of the hepatocytes forms bile canaliculi that transport bile to the hepatic ducts. Parviz et al. (2003) reported that hepatocyte nuclear factor 4-alpha is essential for morphologic and functional differentiation of hepatocytes, accumulation of hepatic glycogen stores, and generation of a hepatic epithelium. They showed that HNF4A is a dominant regulator of the epithelial phenotype because its ectopic expression in fibroblasts induces a mesenchymal-to-epithelial transition. The morphogenetic parameters controlled by HNF4A in hepatocytes are essential for normal liver architecture, including the organization of the sinusoidal endothelium.

By cotransfection in COS-1 cells, Ribeiro et al. (1999) showed that mammalian HNF4 synergized with USF2a (600390) in the transactivation of the APOA2 (107670) promoter. HNF4 and USF2a bound to the enhancer cooperatively, which Ribeiro et al. (1999) suggested may account for the transcriptional synergism observed.

To gain insight into the transcriptional regulatory networks that specify and maintain human tissue diversity, Odom et al. (2004) used chromatin immunoprecipitation combined with promoter microarrays to identify systematically the genes occupied by the transcriptional regulators HNF1-alpha (142410), HNF4-alpha, and HNF6 (604164), together with RNA polymerase II (see 180660), in human liver and pancreatic islets. Odom et al. (2004) identified tissue-specific regulatory circuits formed by HNF1-alpha, HNF4-alpha, and HNF6 with other transcription factors, revealing how these factors function as master regulators of hepatocyte and islet transcription. Odom et al. (2004) concluded that their results suggested how misregulation of HNF4-alpha can contribute to type 2 diabetes (125853). Odom et al. (2004) found that HNF4-alpha bound to the promoters of about 12% of hepatocyte islet genes represented on the microarray. HNF4-alpha acted in a much larger number of hepatocyte and beta-cell genes than did HNF1-alpha, suggesting that HNF4-alpha has broad activities in these 2 tissues.

By microarray and molecular analyses, Battle et al. (2006) found that Hnf4a regulated developmental expression of a myriad of genes encoding proteins required for cell junction assembly and adhesion in developing mouse liver.

Odom et al. (2007) analyzed the binding of HNF3B (600288), HNF1A, HNF4A, and HNF6 to 4,000 orthologous gene pairs in hepatocytes purified from human and mouse livers. Despite the conserved function of these factors, 41 to 89% of the binding events seemed to be species-specific. Importantly, the binding sites varied widely between species in ways that could not be predicted from human-mouse sequence alignments alone.

Saha et al. (2014) showed that mutant IDH1 (147700) and IDH2 (147650) block liver progenitor cells from undergoing hepatocyte differentiation through the production of 2-hydroxyglutarate (2HG) and suppression of HNF4A (600281), a master regulator of hepatocyte identity and quiescence. Correspondingly, genetically engineered mouse models expressing mutant Idh in adult liver showed an aberrant response to hepatic injury, characterized by Hnf4a silencing, impaired hepatocyte differentiation, and markedly elevated levels of cell proliferation. Moreover, IDH and KRAS (190070) mutations, genetic alterations that coexist in a subset of human intrahepatic cholangiocarcinomas (IHCCs), cooperate to drive the expansion of liver progenitor cells, development of premalignant biliary lesions, and progression to metastatic IHCC. Saha et al. (2014) concluded that their studies provided a functional link between IDH mutations, hepatic cell fate, and IHCC pathogenesis, and presented a novel genetically engineered mouse model of IDH-driven malignancy.

Using lineage tracing of the mouse nephron progenitors, Marable et al. (2018) found that Hnf4a is expressed only in the nephron lineage in the developing kidney, in both presumptive proximal tubules and differentiated proximal tubules. Conditional deletion of Hnf4a in the nephron lineage in mouse kidney inhibited the formation of proximal tubules without affecting the formation of the other segments of the nephron, with kidneys of normal size. Further analysis showed that Hnf4a is required for the formation of differentiated proximal tubules but dispensable for the formation of presumptive proximal tubules. Identification and examination of genes that are preferentially expressed in each nephron segment of mouse kidney revealed that the loss of Hnf4a downregulated expression of proximal tubule-specific genes, with minimal changes in the expression of other nephron segment genes, resulting in a reduced number of proximal tubule cells. Moreover, loss of Hnf4a caused reduced expression of genes implicated in renal absorption and urine homeostasis in mouse models, also reflecting the lack of proximal tubule cells in the Hnf4a mutant mouse kidney. Adult Hnf4a mutant mice recapitulated the human Fanconi renotubular syndrome phenotype (see ANIMAL MODEL).

Chen et al. (2019) found that Hnf4a and Hnf4g (605966) colocalized in mouse intestinal epithelial cells and displayed similar expression and DNA-binding profiles. Studies with single- and double-knockout mice showed that Hnf4a and Hnf4g had redundant functions in driving intestinal differentiation. Hnf4a and Hnf4g controlled intestinal differentiation by activating gene expression in intestinal epithelium by binding to distal enhancer regions and maintaining enhancer chromatin activity. The Hnf4 paralogs and Smad4 (600993) bound to regulatory elements of differentiation genes and reciprocally activated expression of each other in intestinal villi. This feed-forward regulatory loop allowed for a robust, enterocyte-specific gene expression program, and disruption of the loop impaired enterocyte differentiation and compromised enterocyte identity.


Molecular Genetics

Maturity-Onset Diabetes of the Young 1

Yamagata et al. (1996) demonstrated a gln268-to-ter mutation (Q268X; 600281.0001) in the gene encoding hepatocyte nuclear factor-4-alpha in a multigeneration family referred to as R-W, in which type I maturity-onset diabetes of the young (MODY1; 125850) was first defined. A member of the steroid/thyroid hormone receptor superfamily, HNF-4-alpha is most highly expressed in liver, kidney, and intestine. It is also expressed in pancreatic islets and insulinoma cells. It is a key regulator of hepatic gene expression and is a major activator of HNF-1-alpha (TCF1), which in turn activates the expression of a large number of liver-specific genes, including those involved in glucose, cholesterol, and fatty acid metabolism. TCF1 is the site of mutations causing type 3 MODY (MODY3; 600496).

Stoffel and Duncan (1997) investigated the molecular mechanism by which the Q268X mutation, which deletes 187 C-terminal amino acids of the HNF4-alpha protein, causes diabetes. They showed that the mutant gene product had lost its transcriptional transactivation activity and failed to dimerize and bind DNA, implying that the MODY1 phenotype is due to a loss of HNF4-alpha function. The effect of loss of function on expression of HNF4-alpha target genes was investigated further in embryonic stem cells, which are amenable to genetic manipulation and can be induced to form visceral endoderm. Because the visceral endoderm shares many properties with the liver and pancreatic beta-cells, including expression of genes for glucose transport and metabolism, it offers an ideal system to investigate HNF4-dependent gene regulation in glucose homeostasis. With this approach, Stoffel and Duncan (1997) identified several genes encoding components of the glucose-dependent insulin secretion pathway whose expression is dependent upon HNF4-alpha. These included glucose transporter-2 (SLC2A2; 138160), and the glycolytic enzymes aldolase B (ALDOB; 612724) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH; 138400), and liver pyruvate kinase (PKLR; 609712). In addition, they found that expression of the fatty acid binding proteins and cellular retinol binding protein also are downregulated in the absence of HNF4-alpha. These data provided direct evidence that HNF4-alpha is critical for regulating glucose transport and glycolysis and in doing so is critical for maintaining glucose homeostasis.

During the course of a search for susceptibility genes contributing to late-onset NIDDM, Zouali et al. (1997) found a suggestion for linkage with markers in the region of the HNF4A/MODY1 gene in a subset of French families with age at onset less than 45 years. This prompted Hani et al. (1998) to screen the HNF4A gene for mutations in 19 French NIDDM families diagnosed before 45 years of age. In 1 family they found a val393-to-ile substitution (600281.0004). This mutation cosegregated with diabetes and impaired insulin secretion. Expression studies showed that the substitution was associated with a marked reduction of transactivation activity, a result consistent with this mutation contributing to the insulin secretory defect observed in the family.

Aguilar-Salinas et al. (2001) investigated possible defects in the insulin sensitivity and the acute insulin response in a group of Mexican patients displaying early-onset NIDDM and evaluated the contribution of mutations in 3 of the genes linked to MODY. They studied 40 Mexican patients diagnosed between 20 and 40 years of age in which the insulin sensitivity as well as the insulin secretory response were measured using the minimal model approach. A partial screening for possible mutations in 3 of the 5 genes linked to MODY was carried out by PCR-SSCP. Among this group they found 2 individuals carrying missense mutations in exon 4 of the HNF4A gene and 1 carrying a nonsense mutation in exon 7 of the HNF1A (142410) gene; 7.5% had positive titers for glutamic acid decarboxylase antibodies. Thirty-five percent of cases had insulin resistance; these subjects had the lipid abnormalities seen in the metabolic syndrome. The authors concluded that a defect in insulin secretion is the hallmark in Mexican diabetic patients diagnosed between 20 and 40 years of age. Mutations in either the HNF1A or the HNF4A genes were present among the individuals who developed early-onset diabetes in their population.

To investigate the properties of naturally occurring HNF4A mutations, Lausen et al. (2000) analyzed 5 MODY1 mutations, including Q268X, R154X (600281.0002), and R127W. Activation of reporter genes in transfection assays and DNA-binding studies showed that the MODY1-associated mutations resulted in a variable reduction in function. None of the MODY1 mutants acted in a dominant-negative manner, thus excluding inactivation of the wildtype factor as a critical event in MODY1 development. A MODY3-associated mutation in the HNF1A gene, a well-known target gene of HNF4A, resulted in dramatic loss of the HNF4-binding site in the promoter, indicating that mutations in the HNF4A gene might cause MODY through impaired HNF1A gene function. Based on these data, Lausen et al. (2000) proposed a 2-hit model for MODY development. Because MODY1 patients are not born with diabetes and initially have no measurable abnormal function in the beta cells of the pancreas, it seemed unlikely that the mutated HNF4A is deficient in a specific function such as interaction with COUP-TF (TFCOUP1; 132890). It seemed more probable that additional events occur with time. Therefore, Lausen et al. (2000) speculated that the function of the wildtype allele was occasionally lost in beta cells, involving either a somatic mutation or some epigenetic event. They imagined that this loss of function of the wildtype allele led to some selective advantage, thus allowing overgrowth of the original beta-cell population.

Fajans et al. (2001) reported that mutation in the HNF4A gene is a relatively uncommon cause of MODY. They stated that only 13 families had been identified as having this form of MODY.

Barrio et al. (2002) estimated the prevalence of major MODY subtypes in Spanish MODY families and analyzed genotype-phenotype correlations. Twenty-two unrelated pediatric MODY patients and 97 relatives were screened for mutations in the coding region of the GCK (138079), HNF1A (142410), and HNF4A genes using PCR-SSCP and/or direct sequencing. Mutations in MODY genes were identified in 64% of the families. One family (4%) carried a novel mutation in the HNF4A gene (IVS5-2delA; 600281.0006), representing the first report of a MODY1 pedigree in the Spanish population. Clinical expression of MODY3 and MODY1 mutations, the second and third groups of defects found, was more severe, including the frequent development of chronic complications.

Johansen et al. (2005) examined the prevalence and nature of mutations in the 3 common MODY genes HNF4A, GCK, and TCF1 (HNF1A) in Danish patients with a clinical diagnosis of MODY and determined metabolic differences in probands with and without mutations in HNF4A, GCK, and TCF1. They identified 29 different mutations in 38 MODY families. Fifteen of the mutations were novel. The variants segregated with diabetes within the families, and none of the variants were found in 100 normal Danish chromosomes. Their findings suggested a relative prevalence of 3% of MODY1 (2 different mutations in 2 families), 10% of MODY2 (7 in 8), and 36% of MODY3 (21 in 28) among Danish kindred clinically diagnosed as MODY. No significant differences in biochemical and anthropometric measurements were observed at baseline examinations. Forty-nine percent of the families carried mutations in the 3 examined MODY genes.

Pearson et al. (2007) studied 108 members of 15 families with MODY due to a mutation in the HNF4A gene and found that birth weights were significantly higher in mutation carriers (p less than 0.001), with 30 (56%) of 54 mutation-positive infants being macrosomic compared to 7 (13%) of 54 mutation-negative infants (p less than 0.001). In addition, 8 of 54 mutation-positive infants had transient hypoglycemia versus none of the 54 mutation-negative infants (p = 0.003), and inappropriate hyperinsulinemia was documented in all 3 hypoglycemic cases tested (see, e.g., 600281.0007). The authors concluded that mutations in HNF4A are associated with increased birth weight and macrosomia, and that the natural history of MODY1 includes hyperinsulinemia at birth that evolves to decreased insulin secretion and diabetes later in life.

Fanconi Renotubular Syndrome 4 with Maturity-Onset Diabetes of the Young

In a girl with Fanconi renotubular syndrome-4 with MODY (FRTS4; 616026), Stanescu et al. (2012) identified a de novo heterozygous missense mutation in the HNF4A gene (R76W; 600281.0008).

Hamilton et al. (2014) identified a heterozygous R76W mutation in 6 individuals from 4 unrelated families with FRTS4 and a pancreatic beta-cell phenotype manifest as macrosomia and neonatal hypoglycemia associated with hyperinsulinemia or MODY. Analysis of urine and serum samples from 20 diabetic patients with other HNF4A mutations showed no evidence of a Fanconi renal phenotype. Hamilton et al. (2014) concluded that this specific mutation is associated with a unique phenotype comprising both MODY and FRTS.

Penetrance of HNF4A Mutations in Diabetes

Mirshahi et al. (2022) comprehensively assessed the penetrance and prevalence of pathogenic variants in HNF1A, HNF4A, and GCK (138079) that account for more than 80% of monogenic diabetes. Mirshahi et al. (2022) analyzed clinical and genetic data from 1,742 clinically referred probands, 2,194 family members, clinically unselected individuals from a US health system-based cohort of 132,194 individuals, and a UK population-based cohort of 198,748 individuals, and found that 1 in 1,500 individuals harbor a pathogenic variant in one of these genes. The penetrance of diabetes for HNF1A and HNF4A pathogenic variants was substantially lower in the clinically unselected individuals compared to clinically referred probands and was dependent on the setting (32% in the population, 49% in the health system cohort, 86% in a family member, and 98% in probands for HNF1A). The relative risk of diabetes was similar across the clinically unselected cohorts, highlighting the role of environment/ other genetic factors. Surprisingly, the penetrance of pathogenic GCK variants was similar (89 to 97%) across all cohorts. The authors suggested that for HNF1A and HNF4A, genetic interpretation and counseling should be tailored to the setting in which a pathogenic monogenic variant was identified. GCK is an exception with near-complete penetrance in all settings.


Animal Model

To study the contribution of HNF4A to hepatic development and differentiation, Li et al. (2000) used a technique in which Hnf4a -/- mouse embryos were complemented with wildtype visceral endoderm to counteract early embryonic lethality. By histologic analyses, the authors found that specification and early development of the liver and liver morphology did not require Hnf4a. In addition, the expression of many liver genes was unaffected in these mice. However, RT-PCR analysis showed that Hnf4a -/- fetal livers failed to express a large array of genes whose expression in differentiated hepatocytes is essential for a functional hepatic parenchyma, including apolipoproteins (e.g., APOA1, 107680), metabolic proteins (e.g., aldolase B, 612724), transferrin (190000), retinol-binding protein (e.g., RBP4, 180250), and erythropoietin (133170). The lack of Hnf4a did not affect the expression of most transcription factors but did significantly reduce the levels of Hnf1a (TCF1; 142410) and the pregnane X receptor (NR1I2; 603065), suggesting that HNF4A acts upstream of at least these 2 transcription factors, which are also important in hepatocyte gene expression.

In mice with a conditional deletion of Hnf4a in pancreatic beta cells, Gupta et al. (2005) observed hyperinsulinemia in fasted and fed animals but also impaired glucose tolerance. Islet perifusion and calcium-imaging studies showed abnormal beta cell responses to stimulation by glucose and sulfonylureas, explainable in part by a 60% reduction in expression of the potassium channel subunit Kir6.2 (KCNJ11; 600937). Cotransfection assays revealed that the Kir6.2 gene is a transcriptional target of HNF4A. Gupta et al. (2005) concluded that HNF4A is required in the pancreatic beta cell for regulation of the pathway of insulin secretion dependent on the ATP-dependent potassium channel.

Pearson et al. (2007) generated mice with pancreatic beta-cell deletion of Hnf4a and observed hyperinsulinemia in utero and hyperinsulinemic hypoglycemia at birth.

Sekiya and Suzuki (2011) screened the effects of 12 candidate factors to identify 3 specific combinations of 2 transcription factors, comprising Hnf4-alpha plus Foxa1 (602294), Foxa2 (600288), or Foxa3 (602295), that can convert mouse embryonic and adult fibroblasts into cells that closely resemble hepatocytes in vitro. The induced hepatocyte-like (iHep) cells had multiple hepatocyte-specific features and reconstituted damaged hepatic tissues after transplantation.

Marable et al. (2018) generated mice with Cre-mediated deletion of Hnf4a in the nephron lineage. Hnf4a mutant mice consumed more water and excreted more urine than control mice due to reduced expression of water transporter genes in Hnf4a mutant kidneys. The urine of Hnf4a mutant mice contained more glucose and phosphate than that of controls because loss of Hnf4a resulted in the loss of glucose and phosphate transporters in proximal tubules, recapitulating a Fanconi renotubular syndrome (FRTS4; 616026)-like phenotype. In addition, adult Hnf4a mutant mice had smaller kidneys with highly disorganized and fewer proximal tubules, and displayed nephrocalcinosis resulting from calcium accumulation in renal tubules, confirming that Hnf4a mutant mice recapitulate the FRTS patient phenotype.


Evolution

To explore the evolution of gene regulation, Schmidt et al. (2010) used chromatin immunoprecipitation with high-throughput sequencing (ChIP-seq) to determine experimentally the genomewide occupancy of 2 transcription factors, CEBPA (116897) and HNF4A, in the livers of 5 vertebrates, Homo sapiens, Mus musculus, Canis familiaris, Monodelphis domesticus (short-tailed opossum), and Gallus gallus. Although each transcription factor displayed highly conserved DNA binding preferences, most binding was species-specific, and aligned binding events present in all 5 species were rare. Regions near genes with expression levels that are dependent on a transcription factor were often bound by the transcription factor in multiple species yet showed no enhanced DNA sequence constraint. Binding divergence between species can be largely explained by sequence changes to the bound motifs. Among the binding events lost in one lineage, only half are recovered by another binding event within 10 kb. Schmidt et al. (2010) concluded that their results revealed large interspecies differences in transcriptional regulation and provided insight into regulatory evolution.


ALLELIC VARIANTS ( 8 Selected Examples):

.0001 MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, GLN268TER
  
RCV000009790...

In the historic R-W pedigree in which Fajans (1989) defined type 1 maturity-onset diabetes of the young (125850), Yamagata et al. (1996) found a C-to-T substitution in codon 268 of the TCF14 gene that generated a CAG-to-TAG (Q268X) nonsense mutation. Some subjects in the R-W pedigree had inherited the Q268X mutation but were not yet diabetic; in addition, there were subjects in the pedigree who had noninsulin-dependent diabetes mellitus but did not inherit the Q268X mutation or at-risk haplotype. In one case, NIDDM had been diagnosed at the age of 48 years, and the patient was hyperinsulinemic, indicating that this was probably late-onset NIDDM rather than MODY. The patient had 6 children, 1 of whom also had NIDDM; another child had impaired glucose tolerance, and all had only normal alleles at the TCF14 locus.


.0002 MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, ARG154TER
  
RCV000009791...

Lindner et al. (1997) reported a second nonsense mutation in the HNF4-alpha gene in a 3-generation MODY1 (125850) pedigree, Dresden-11. A C-to-T transition resulted in an arg-to-ter mutation at codon 154 (R154X). Extensive clinical studies of 6 affected members of this family showed severe diabetes requiring insulin or oral hypoglycemic agents, but no liver or renal abnormalities. These results suggested to Lindner et al. (1997) that despite expression of HNF4-alpha in liver, kidney, intestine, and pancreas, nonsense mutations in HNF4-alpha appear to affect only pancreatic beta-cell function.

Eeckhoute et al. (2001) reported that loss of HNF4-alpha function by R154X is increased through impaired physical interaction and functional cooperation between HNF4-alpha and p300 (602700).


.0003 MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, ARG127TRP
  
RCV000009792...

In 3 of 5 members with MODY (125850) in 1 family, Furuta et al. (1997) identified an arg127-to-trp (R127W) mutation resulting from a transition from CGG to TGG. The mutation was located in the T-box, a region of the protein that may play a role in HNF-4-alpha dimerization and DNA binding. The findings in the family suggested that the R172W mutation was not the only cause of diabetes. The overall results suggested that mutations in the HNF4A gene may cause early onset NIDDM/MODY in Japanese but such mutations are less common than mutations in the HNF1A/MODY3 gene (142410).


.0004 TYPE 2 DIABETES MELLITUS

HNF4A, VAL393ILE
  
RCV000009793...

In a single French family with T2D (125853) diagnosed before the age of 45 years, Hani et al. (1998) found a val393-to-ile amino acid substitution in the TCF14 gene. Expression studies showed a marked reduction of transactivation activity, a result consistent with this mutation contributing to the insulin secretory defect observed in the family.


.0005 MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, 1-BP DEL, PHE75T
   RCV000009794

To determine the prevalence of MODY caused by HNF4-alpha mutations (MODY1; 125850), Moller et al. (1999) screened 10 Danish non-MODY3 probands for mutations in the minimal promoter and the 12 exons of the HNF4-alpha gene. One proband had a frameshift mutation (Phe75fsdelT) in exon 2 resulting in a premature termination after 117 amino acids. The authors concluded that defects in the HNF4-alpha gene are a rare cause of MODY in Denmark.


.0006 MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, IVS5, DEL A, -2
  
RCV000009795...

In a Spanish family with MODY (125850), Barrio et al. (2002) found a deletion of an A nucleotide at the canonic acceptor splice site of exon 6. The pedigree exhibited a severe form of diabetes with a high incidence of chronic complications. The proband was diagnosed at 15 years of age. This represented the first report of a MODY1 pedigree in the Spanish population.


.0007 MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, MET364ARG
  
RCV000009796

In affected members of a 3-generation family with MODY (125850), Pearson et al. (2007) identified heterozygosity for a 1091T-G transversion in the HNF4A gene, resulting in a met364-to-arg (M364R) substitution. A 16-year-old girl and her 15-year-old brother were macrosomic at birth and hypoglycemic in the first 24 hours of life, and the sister also had documented inappropriate hyperinsulinemia in the presence of hypoglycemia; both later developed diabetes, at 12 and 14 years of age, respectively. Their mother, maternal aunt, and maternal grandmother had developed diabetes at ages 31, 18, and 40 years, respectively.


.0008 FANCONI RENOTUBULAR SYNDROME 4, WITH MATURITY-ONSET DIABETES OF THE YOUNG

HNF4A, ARG76TRP
  
RCV000144170...

In a girl with Fanconi renotubular syndrome-4 with MODY (FRTS4; 616026), Stanescu et al. (2012) identified a de novo heterozygous c.226C-T transition in the HNF4A gene, resulting in an arg76-to-trp (R76W) substitution. Functional studies of the variant were not performed.

Hamilton et al. (2014) identified a heterozygous R76W mutation in 3 members of a family with FRTS4 and a pancreatic beta-cell phenotype manifest as macrosomia and neonatal hypoglycemia associated with hyperinsulinemia. The mutation arose in the proband's maternal grandfather, who carried the germline and somatic mosaic form of the mutation (26% mutation in leukocyte DNA). Three additional unrelated carriers of the heterozygous R76W mutation were subsequently identified from a cohort of 147 probands with HNF4A mutations; all had the Fanconi renal phenotype with nephrocalcinosis. The R76W mutation, which occurs in the DNA-binding domain, was hypothesized to cause defective interaction with major regulatory genes; however, functional studies were not performed. Hamilton et al. (2014) concluded that this specific mutation is associated with a unique phenotype comprising both MODY and FRTS.


REFERENCES

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  17. Johansen, A., Ek, J., Mortensen, H. B., Pedersen, O., Hansen, T. Half of clinically defined maturity-onset diabetes of the young patients in Denmark do not have mutations in HNF4A, GCK, and TCF1. J. Clin. Endocr. Metab. 90: 4607-4614, 2005. [PubMed: 15928245, related citations] [Full Text]

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  19. Li, J., Ning, G., Duncan, S. A. Mammalian hepatocyte differentiation requires the transcription factor HNF-4-alpha. Genes Dev. 14: 464-474, 2000. [PubMed: 10691738, images, related citations]

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  21. Marable, S. S., Chung, E., Adam, M., Potter, S. S., Park, J.-S. Hnf4a deletion in the mouse kidney phenocopies Fanconi renotubular syndrome. JCI Insight 3: 97497, 2018. Note: Electronic Article. [PubMed: 30046000, images, related citations] [Full Text]

  22. Mirshahi, U. L., Colclough, K., Wright, C. F., Wood, A. R., Beaumont, R. N., Tyrrell, J., Laver, T. W., Stahl, R., Golden, A., Goehringer, J. M, Geisinger-Regeneron DiscovEHR Collaboration, Frayling, T. F., Hattersley, A. T., Carey, D. J., Weedon, M. N., Patel, K. A. Reduced penetrance of MODY-associated HNF1A/HNF4A variants but not GCK variants in clinically unselected cohorts. Am. J. Hum. Genet. 109: 2018-2028, 2022. [PubMed: 36257325, images, related citations] [Full Text]

  23. Moller, A. M., Dalgaard, L. T., Ambye, L., Hansen, L., Schmitz, O., Hansen, T., Pedersen, O. A novel Phe75fsdelT mutation in the hepatocyte nuclear factor-4-alpha gene in a Danish pedigree with maturity-onset diabetes of the young. J. Clin. Endocr. Metab. 84: 367-369, 1999. [PubMed: 9920109, related citations] [Full Text]

  24. Odom, D. T., Dowell, R. D., Jacobsen, E. S., Gordon, W., Danford, T. W., MacIsaac, K. D., Rolfe, P. A., Conboy, C. M., Gifford, D. K., Fraenkel, E. Tissue-specific transcriptional regulation has diverged significantly between human and mouse. Nature Genet. 39: 730-732, 2007. [PubMed: 17529977, images, related citations] [Full Text]

  25. Odom, D. T., Zizlsperger, N., Gordon, D. B., Bell, G. W., Rinaldi, N. J., Murray, H. L., Volkert, T. L., Schreiber, J., Rolfe, P. A., Gifford, D. K., Fraenkel, E., Bell, G. I., Young, R. A. Control of pancreas and liver gene expression by HNF transcription factors. Science 303: 1378-1381, 2004. [PubMed: 14988562, images, related citations] [Full Text]

  26. Parviz, F., Matullo, C., Garrison, W. D., Savatski, L., Adamson, J. W., Ning, G., Kaestner, K. H., Rossi, J. M., Zaret, K. S., Duncan, S. A. Hepatocyte nuclear factor 4-alpha controls the development of a hepatic epithelium and liver morphogenesis. Nature Genet. 34: 292-296, 2003. [PubMed: 12808453, related citations] [Full Text]

  27. Pearson, E. R., Boj, S. F., Steele, A. M., Barrett, T., Stals, K., Shield, J. P., Ellard, S., Ferrer, J., Hattersley, A. T. Macrosomia and hyperinsulinaemic hypoglycaemia in patients with heterozygous mutations in the HNF4A gene. PLoS Med. 4: e118, 2007. Note: Electronic Article. [PubMed: 17407387, images, related citations] [Full Text]

  28. Ribeiro, A., Pastier, D., Kardassis, D., Chambaz, J., Cardot, P. Cooperative binding of upstream stimulatory factor and hepatic nuclear factor 4 drives the transcription of the human apolipoprotein A-II gene. J. Biol. Chem. 274: 1216-1225, 1999. [PubMed: 9880489, related citations] [Full Text]

  29. Saha, S. K., Parachoniak, C. A., Ghanta, K. S., Fitamant, J., Ross, K. N., Najem, M. S., Gurumurthy, S., Akbay, E. A., Sia, D., Cornella, H., Miltiadous, O., Walesky, C., and 14 others. Mutant IDH inhibits HNF-4-alpha to block hepatocyte differentiation and promote biliary cancer. Nature 513: 110-114, 2014. Note: Erratum: Nature 519: 118 only, 2015. Note: Erratum: Nature 528: 152 only, 2015. [PubMed: 25043045, images, related citations] [Full Text]

  30. Schmidt, D., Wilson, M. D., Ballester, B., Schwalie, P. C., Brown, G. D., Marshall, A., Kutter, C., Watt, S., Martinez-Jimenez, C. P., Mackay, S., Talianidis, I., Flicek, P., Odom, D. T. Five-vertebrate ChIP-seq reveals the evolutionary dynamics of transcription factor binding. Science 328: 1036-1040, 2010. [PubMed: 20378774, images, related citations] [Full Text]

  31. Sekiya, S., Suzuki, A. Direct conversion of mouse fibroblasts to hepatocyte-like cells by defined factors. Nature 475: 390-393, 2011. [PubMed: 21716291, related citations] [Full Text]

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  33. Stoffel, M., Duncan, S. A. The maturity-onset diabetes of the young (MODY1) transcription factor HNF4-alpha regulates expression of genes required for glucose transport and metabolism. Proc. Nat. Acad. Sci. 94: 13209-13214, 1997. [PubMed: 9371825, images, related citations] [Full Text]

  34. Thomas, H., Jaschkowitz, K., Bulman, M., Frayling, T. M., Mitchell, S. M. S., Roosen, S., Lingott-Frieg, A., Tack, C. J., Ellard, S., Ryffel, G. U., Hattersley, A. T. A distant upstream promoter of the HNF-4-alpha gene connects the transcription factors involved in maturity-onset diabetes of the young. Hum. Molec. Genet. 10: 2089-2097, 2001. [PubMed: 11590126, related citations] [Full Text]

  35. Tirona, R. G., Lee, W., Leake, B. F., Lan, L.-B., Cline, C. B., Lamba, V., Parviz, F., Duncan, S. A., Inoue, Y., Gonzalez, F. J., Schuetz, E. G., Kim, R. B. The orphan nuclear receptor HNF4-alpha determines PXR- and CAR-mediated xenobiotic induction of CYP3A4. Nature Med. 9: 220-224, 2003. [PubMed: 12514743, related citations] [Full Text]

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  37. Zouali, H., Hani, E. H., Philippi, A., Vionnet, N., Beckmann, J. S., Demenais, F., Froguel, P. A susceptibility locus for early-onset non-insulin dependent (type 2) diabetes mellitus maps to chromosome 20q, proximal to the phosphoenolpyruvate carboxykinase gene. Hum. Molec. Genet. 6: 1401-1408, 1997. [PubMed: 9285775, related citations] [Full Text]


Ada Hamosh - updated : 01/17/2023
Bao Lige - updated : 07/02/2019
Bao Lige - updated : 10/02/2018
Ada Hamosh - updated : 10/3/2014
Matthew B. Gross - updated : 9/30/2014
Cassandra L. Kniffin - updated : 9/23/2014
Ada Hamosh - updated : 7/16/2013
Ada Hamosh - updated : 8/4/2011
Ada Hamosh - updated : 6/30/2010
Marla J. F. O'Neill - updated : 5/6/2008
Patricia A. Hartz - updated : 8/3/2007
John A. Phillips, III - updated : 10/19/2006
Patricia A. Hartz - updated : 7/11/2006
Marla J. F. O'Neill - updated : 7/8/2005
Ada Hamosh - updated : 6/10/2004
Patricia A. Hartz - updated : 5/7/2004
Victor A. McKusick - updated : 6/16/2003
Victor A. McKusick - updated : 1/15/2003
John A. Phillips, III - updated : 1/9/2003
John A. Phillips, III - updated : 7/12/2002
George E. Tiller - updated : 2/8/2002
Ada Hamosh - updated : 10/18/2001
John A. Phillips, III - updated : 9/25/2001
Paul J. Converse - updated : 9/5/2000
Victor A. McKusick - updated : 2/4/2000
John A. Phillips, III - updated : 11/17/1999
Victor A. McKusick - updated : 3/20/1998
Victor A. McKusick - updated : 2/24/1998
Victor A. McKusick - updated : 2/13/1998
Ada Hamosh - updated : 10/20/1997
Victor A. McKusick - updated : 2/11/1997
Creation Date:
Victor A. McKusick : 1/5/1995
alopez : 01/17/2023
carol : 09/02/2020
carol : 07/08/2019
mgross : 07/02/2019
alopez : 10/02/2018
joanna : 07/21/2016
carol : 07/20/2016
alopez : 07/18/2016
alopez : 3/11/2015
alopez : 10/3/2014
mgross : 9/30/2014
alopez : 9/24/2014
mcolton : 9/23/2014
ckniffin : 9/23/2014
alopez : 7/16/2013
tpirozzi : 7/12/2013
alopez : 8/15/2011
terry : 8/4/2011
alopez : 7/1/2010
alopez : 7/1/2010
terry : 6/30/2010
carol : 4/14/2009
terry : 2/19/2009
carol : 5/8/2008
terry : 5/6/2008
alopez : 8/3/2007
alopez : 10/19/2006
mgross : 7/11/2006
mgross : 7/11/2006
terry : 7/11/2006
carol : 11/18/2005
terry : 7/8/2005
alopez : 6/15/2004
terry : 6/10/2004
mgross : 5/7/2004
alopez : 7/28/2003
alopez : 6/16/2003
terry : 6/16/2003
carol : 5/28/2003
alopez : 2/28/2003
alopez : 1/15/2003
alopez : 1/9/2003
tkritzer : 12/10/2002
alopez : 7/12/2002
alopez : 7/12/2002
cwells : 2/19/2002
cwells : 2/8/2002
carol : 10/18/2001
cwells : 9/28/2001
cwells : 9/25/2001
mgross : 9/5/2000
mcapotos : 2/29/2000
mcapotos : 2/15/2000
mcapotos : 2/15/2000
terry : 2/4/2000
alopez : 11/17/1999
alopez : 11/17/1999
carol : 8/26/1998
alopez : 8/25/1998
dkim : 7/21/1998
dholmes : 4/17/1998
alopez : 3/25/1998
terry : 3/20/1998
alopez : 2/25/1998
terry : 2/24/1998
mark : 2/22/1998
terry : 2/13/1998
alopez : 12/8/1997
alopez : 11/19/1997
jamie : 5/7/1997
jenny : 3/31/1997
terry : 2/11/1997
mark : 12/4/1996
terry : 12/3/1996
mark : 12/7/1995
carol : 1/5/1995

* 600281

HEPATOCYTE NUCLEAR FACTOR 4-ALPHA; HNF4A


Alternative titles; symbols

HNF4-ALPHA
HEPATOCYTE NUCLEAR FACTOR 4; HNF4
TRANSCRIPTION FACTOR 14, HEPATIC NUCLEAR FACTOR; TCF14


HGNC Approved Gene Symbol: HNF4A

SNOMEDCT: 44054006, 609562003;   ICD10CM: E11;  


Cytogenetic location: 20q13.12     Genomic coordinates (GRCh38): 20:44,355,699-44,434,596 (from NCBI)


Gene-Phenotype Relationships

Location Phenotype Phenotype
MIM number
Inheritance Phenotype
mapping key
20q13.12 {Diabetes mellitus, noninsulin-dependent} 125853 Autosomal dominant 3
Fanconi renotubular syndrome 4, with maturity-onset diabetes of the young 616026 Autosomal dominant 3
MODY, type I 125850 Autosomal dominant 3

TEXT

Description

The hepatocyte nuclear factor-4-alpha (HNF4A) is a member of the nuclear receptor family of transcription factors and is the most abundant DNA-binding protein in the liver, where it regulates genes largely involved in the hepatic gluconeogenic program and lipid metabolism (summary by Chandra et al., 2013).


Cloning and Expression

Cell specificity is based on differential gene expression, which is in turn determined, at least in part, by a particular set of transcription factors present and active in a given cell at a certain time. Isoforms of a transcription factor can be expressed at different stages of cell differentiation. Many transcription factors have been identified and characterized, particularly in the liver where there is a wide range of transcriptionally controlled genes. The extinction of many hepatic functions and their reexpression are correlated with the extinction and expression of hepatocyte nuclear factor-4 (HNF4). Moreover, HNF4 has a key role in a transcriptional hierarchy since it also controls the expression of the transcription factor HNF1 (TCF1; 142410), which is important in the expression of several hepatic genes. Chartier et al. (1994) demonstrated that there are 2 isoforms of HNF4 in human liver, a situation comparable to that in the rat. The 2 isoforms differ by an extra peptide of 10 amino acids located in the C-terminal part of the protein. The gene is also symbolized TCF14.


Gene Structure

Furuta et al. (1997) reported the exon/intron organization and partial sequence of the HNF4A gene. In addition, they screened 12 exons, flanking introns and minimal promoter regions for mutations in a group of 57 unrelated Japanese subjects with early-onset noninsulin-dependent diabetes mellitus (NIDDM; 125853)/maturity-onset diabetes of the young (MODY, see 125850) of unknown cause. They identified an arg127-to-trp mutation (R127W; 600281.0003) in 3 of 5 diabetic members of one family.

Thomas et al. (2001) identified an alternative promoter of the HNF4A gene, P2, which is 46 kb 5-prime to the previously identified P1 promoter of the human gene. Based on RT-PCR, this distant upstream P2 promoter represents the major transcription site in pancreatic beta-cells, and is also used in hepatic cells. Transfection assays with various deletions and mutants of the P2 promoter revealed functional binding sites for HNF1A (142410), HNF1B (189907), and IPF1 (600733), the other transcription factors known to encode MODY genes. In a large MODY family, a mutated IPF1 binding site in the P2 promoter of the HNF4A gene cosegregated with diabetes (lod score 3.25). The authors proposed a regulatory network of the 4 MODY transcription factors interconnected at the distant upstream P2 promoter of the HNF4A gene.


Mapping

Argyrokastritis et al. (1997) used genetic linkage analysis and fluorescence in situ hybridization to map HNF4 to chromosome 20, in a region syntenic with mouse chromosome 2, where the hnf4 homolog had been assigned by Avraham et al. (1992).

Gross (2014) mapped the HNF4A gene to chromosome 20q13.12 based on an alignment of the HNF4A sequence (GenBank BC137539) with the genomic sequence (GRCh38).


Biochemical Features

Crystal Structure

Chandra et al. (2013) described the 2.9-angstrom crystal structure of the multidomain human HNF4-alpha homodimer bound to its DNA response element and coactivator-derived peptides. A convergence zone connects multiple receptor domains in an asymmetric fashion, joining distinct elements from each monomer. An arginine target of PRMT1 (602950) methylation protrudes directly into this convergence zone and sustains its integrity. A serine target of protein kinase C (see 176960) is also responsible for maintaining domain-domain interactions. These posttranslational modifications lead to changes in DNA binding by communicating through the tightly connected surfaces of the quaternary fold. Chandra et al. (2013) found that some mutations resulting in MODY1 (125850), positioned on the ligand-binding domain and hinge regions of the receptor, compromise DNA binding at a distance by communicating through the interjunctional surfaces of the complex. The overall domain representation of the HNF4-alpha homodimer is different from that of the PPAR-gamma (601487)-RXR-alpha (180245) heterodimer, even when both nuclear receptor complexes are assembled on the same DNA element.


Gene Function

Tirona et al. (2003) showed that HNF4A is critically involved in the PXR (603065)- and CAR (603881)-mediated transcriptional activation of CYP3A4 (124010). They identified a specific cis-acting element in the CYP3A4 gene enhancer that confers HNF4-alpha binding and thereby permits PXR- and CAR-mediated gene activation. Fetal mice with conditional deletion of Hnf4-alpha had reduced or absent expression of CYP3A. Furthermore, adult mice with conditional hepatic deletion of the gene had reduced basal and inducible expression of CYP3A. These data identified HNF4-alpha as an important regulator of coordinate nuclear receptor-mediated response to xenobiotics. To elucidate how differentiated cells form tissues and organs, Parviz et al. (2003) studied liver organogenesis because the cell and tissue architecture of this organ is well defined. Approximately 60% of the adult liver consists of hepatocytes that are arranged as single-cell anastomosing plates extending from the portal region of the liver lobule toward the central vein. The basal surface of the hepatocytes is separated from adjacent sinusoidal endothelial cells by the space of Disse, where the exchange of substances between serum and hepatocytes takes place. The apical surface of the hepatocytes forms bile canaliculi that transport bile to the hepatic ducts. Parviz et al. (2003) reported that hepatocyte nuclear factor 4-alpha is essential for morphologic and functional differentiation of hepatocytes, accumulation of hepatic glycogen stores, and generation of a hepatic epithelium. They showed that HNF4A is a dominant regulator of the epithelial phenotype because its ectopic expression in fibroblasts induces a mesenchymal-to-epithelial transition. The morphogenetic parameters controlled by HNF4A in hepatocytes are essential for normal liver architecture, including the organization of the sinusoidal endothelium.

By cotransfection in COS-1 cells, Ribeiro et al. (1999) showed that mammalian HNF4 synergized with USF2a (600390) in the transactivation of the APOA2 (107670) promoter. HNF4 and USF2a bound to the enhancer cooperatively, which Ribeiro et al. (1999) suggested may account for the transcriptional synergism observed.

To gain insight into the transcriptional regulatory networks that specify and maintain human tissue diversity, Odom et al. (2004) used chromatin immunoprecipitation combined with promoter microarrays to identify systematically the genes occupied by the transcriptional regulators HNF1-alpha (142410), HNF4-alpha, and HNF6 (604164), together with RNA polymerase II (see 180660), in human liver and pancreatic islets. Odom et al. (2004) identified tissue-specific regulatory circuits formed by HNF1-alpha, HNF4-alpha, and HNF6 with other transcription factors, revealing how these factors function as master regulators of hepatocyte and islet transcription. Odom et al. (2004) concluded that their results suggested how misregulation of HNF4-alpha can contribute to type 2 diabetes (125853). Odom et al. (2004) found that HNF4-alpha bound to the promoters of about 12% of hepatocyte islet genes represented on the microarray. HNF4-alpha acted in a much larger number of hepatocyte and beta-cell genes than did HNF1-alpha, suggesting that HNF4-alpha has broad activities in these 2 tissues.

By microarray and molecular analyses, Battle et al. (2006) found that Hnf4a regulated developmental expression of a myriad of genes encoding proteins required for cell junction assembly and adhesion in developing mouse liver.

Odom et al. (2007) analyzed the binding of HNF3B (600288), HNF1A, HNF4A, and HNF6 to 4,000 orthologous gene pairs in hepatocytes purified from human and mouse livers. Despite the conserved function of these factors, 41 to 89% of the binding events seemed to be species-specific. Importantly, the binding sites varied widely between species in ways that could not be predicted from human-mouse sequence alignments alone.

Saha et al. (2014) showed that mutant IDH1 (147700) and IDH2 (147650) block liver progenitor cells from undergoing hepatocyte differentiation through the production of 2-hydroxyglutarate (2HG) and suppression of HNF4A (600281), a master regulator of hepatocyte identity and quiescence. Correspondingly, genetically engineered mouse models expressing mutant Idh in adult liver showed an aberrant response to hepatic injury, characterized by Hnf4a silencing, impaired hepatocyte differentiation, and markedly elevated levels of cell proliferation. Moreover, IDH and KRAS (190070) mutations, genetic alterations that coexist in a subset of human intrahepatic cholangiocarcinomas (IHCCs), cooperate to drive the expansion of liver progenitor cells, development of premalignant biliary lesions, and progression to metastatic IHCC. Saha et al. (2014) concluded that their studies provided a functional link between IDH mutations, hepatic cell fate, and IHCC pathogenesis, and presented a novel genetically engineered mouse model of IDH-driven malignancy.

Using lineage tracing of the mouse nephron progenitors, Marable et al. (2018) found that Hnf4a is expressed only in the nephron lineage in the developing kidney, in both presumptive proximal tubules and differentiated proximal tubules. Conditional deletion of Hnf4a in the nephron lineage in mouse kidney inhibited the formation of proximal tubules without affecting the formation of the other segments of the nephron, with kidneys of normal size. Further analysis showed that Hnf4a is required for the formation of differentiated proximal tubules but dispensable for the formation of presumptive proximal tubules. Identification and examination of genes that are preferentially expressed in each nephron segment of mouse kidney revealed that the loss of Hnf4a downregulated expression of proximal tubule-specific genes, with minimal changes in the expression of other nephron segment genes, resulting in a reduced number of proximal tubule cells. Moreover, loss of Hnf4a caused reduced expression of genes implicated in renal absorption and urine homeostasis in mouse models, also reflecting the lack of proximal tubule cells in the Hnf4a mutant mouse kidney. Adult Hnf4a mutant mice recapitulated the human Fanconi renotubular syndrome phenotype (see ANIMAL MODEL).

Chen et al. (2019) found that Hnf4a and Hnf4g (605966) colocalized in mouse intestinal epithelial cells and displayed similar expression and DNA-binding profiles. Studies with single- and double-knockout mice showed that Hnf4a and Hnf4g had redundant functions in driving intestinal differentiation. Hnf4a and Hnf4g controlled intestinal differentiation by activating gene expression in intestinal epithelium by binding to distal enhancer regions and maintaining enhancer chromatin activity. The Hnf4 paralogs and Smad4 (600993) bound to regulatory elements of differentiation genes and reciprocally activated expression of each other in intestinal villi. This feed-forward regulatory loop allowed for a robust, enterocyte-specific gene expression program, and disruption of the loop impaired enterocyte differentiation and compromised enterocyte identity.


Molecular Genetics

Maturity-Onset Diabetes of the Young 1

Yamagata et al. (1996) demonstrated a gln268-to-ter mutation (Q268X; 600281.0001) in the gene encoding hepatocyte nuclear factor-4-alpha in a multigeneration family referred to as R-W, in which type I maturity-onset diabetes of the young (MODY1; 125850) was first defined. A member of the steroid/thyroid hormone receptor superfamily, HNF-4-alpha is most highly expressed in liver, kidney, and intestine. It is also expressed in pancreatic islets and insulinoma cells. It is a key regulator of hepatic gene expression and is a major activator of HNF-1-alpha (TCF1), which in turn activates the expression of a large number of liver-specific genes, including those involved in glucose, cholesterol, and fatty acid metabolism. TCF1 is the site of mutations causing type 3 MODY (MODY3; 600496).

Stoffel and Duncan (1997) investigated the molecular mechanism by which the Q268X mutation, which deletes 187 C-terminal amino acids of the HNF4-alpha protein, causes diabetes. They showed that the mutant gene product had lost its transcriptional transactivation activity and failed to dimerize and bind DNA, implying that the MODY1 phenotype is due to a loss of HNF4-alpha function. The effect of loss of function on expression of HNF4-alpha target genes was investigated further in embryonic stem cells, which are amenable to genetic manipulation and can be induced to form visceral endoderm. Because the visceral endoderm shares many properties with the liver and pancreatic beta-cells, including expression of genes for glucose transport and metabolism, it offers an ideal system to investigate HNF4-dependent gene regulation in glucose homeostasis. With this approach, Stoffel and Duncan (1997) identified several genes encoding components of the glucose-dependent insulin secretion pathway whose expression is dependent upon HNF4-alpha. These included glucose transporter-2 (SLC2A2; 138160), and the glycolytic enzymes aldolase B (ALDOB; 612724) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH; 138400), and liver pyruvate kinase (PKLR; 609712). In addition, they found that expression of the fatty acid binding proteins and cellular retinol binding protein also are downregulated in the absence of HNF4-alpha. These data provided direct evidence that HNF4-alpha is critical for regulating glucose transport and glycolysis and in doing so is critical for maintaining glucose homeostasis.

During the course of a search for susceptibility genes contributing to late-onset NIDDM, Zouali et al. (1997) found a suggestion for linkage with markers in the region of the HNF4A/MODY1 gene in a subset of French families with age at onset less than 45 years. This prompted Hani et al. (1998) to screen the HNF4A gene for mutations in 19 French NIDDM families diagnosed before 45 years of age. In 1 family they found a val393-to-ile substitution (600281.0004). This mutation cosegregated with diabetes and impaired insulin secretion. Expression studies showed that the substitution was associated with a marked reduction of transactivation activity, a result consistent with this mutation contributing to the insulin secretory defect observed in the family.

Aguilar-Salinas et al. (2001) investigated possible defects in the insulin sensitivity and the acute insulin response in a group of Mexican patients displaying early-onset NIDDM and evaluated the contribution of mutations in 3 of the genes linked to MODY. They studied 40 Mexican patients diagnosed between 20 and 40 years of age in which the insulin sensitivity as well as the insulin secretory response were measured using the minimal model approach. A partial screening for possible mutations in 3 of the 5 genes linked to MODY was carried out by PCR-SSCP. Among this group they found 2 individuals carrying missense mutations in exon 4 of the HNF4A gene and 1 carrying a nonsense mutation in exon 7 of the HNF1A (142410) gene; 7.5% had positive titers for glutamic acid decarboxylase antibodies. Thirty-five percent of cases had insulin resistance; these subjects had the lipid abnormalities seen in the metabolic syndrome. The authors concluded that a defect in insulin secretion is the hallmark in Mexican diabetic patients diagnosed between 20 and 40 years of age. Mutations in either the HNF1A or the HNF4A genes were present among the individuals who developed early-onset diabetes in their population.

To investigate the properties of naturally occurring HNF4A mutations, Lausen et al. (2000) analyzed 5 MODY1 mutations, including Q268X, R154X (600281.0002), and R127W. Activation of reporter genes in transfection assays and DNA-binding studies showed that the MODY1-associated mutations resulted in a variable reduction in function. None of the MODY1 mutants acted in a dominant-negative manner, thus excluding inactivation of the wildtype factor as a critical event in MODY1 development. A MODY3-associated mutation in the HNF1A gene, a well-known target gene of HNF4A, resulted in dramatic loss of the HNF4-binding site in the promoter, indicating that mutations in the HNF4A gene might cause MODY through impaired HNF1A gene function. Based on these data, Lausen et al. (2000) proposed a 2-hit model for MODY development. Because MODY1 patients are not born with diabetes and initially have no measurable abnormal function in the beta cells of the pancreas, it seemed unlikely that the mutated HNF4A is deficient in a specific function such as interaction with COUP-TF (TFCOUP1; 132890). It seemed more probable that additional events occur with time. Therefore, Lausen et al. (2000) speculated that the function of the wildtype allele was occasionally lost in beta cells, involving either a somatic mutation or some epigenetic event. They imagined that this loss of function of the wildtype allele led to some selective advantage, thus allowing overgrowth of the original beta-cell population.

Fajans et al. (2001) reported that mutation in the HNF4A gene is a relatively uncommon cause of MODY. They stated that only 13 families had been identified as having this form of MODY.

Barrio et al. (2002) estimated the prevalence of major MODY subtypes in Spanish MODY families and analyzed genotype-phenotype correlations. Twenty-two unrelated pediatric MODY patients and 97 relatives were screened for mutations in the coding region of the GCK (138079), HNF1A (142410), and HNF4A genes using PCR-SSCP and/or direct sequencing. Mutations in MODY genes were identified in 64% of the families. One family (4%) carried a novel mutation in the HNF4A gene (IVS5-2delA; 600281.0006), representing the first report of a MODY1 pedigree in the Spanish population. Clinical expression of MODY3 and MODY1 mutations, the second and third groups of defects found, was more severe, including the frequent development of chronic complications.

Johansen et al. (2005) examined the prevalence and nature of mutations in the 3 common MODY genes HNF4A, GCK, and TCF1 (HNF1A) in Danish patients with a clinical diagnosis of MODY and determined metabolic differences in probands with and without mutations in HNF4A, GCK, and TCF1. They identified 29 different mutations in 38 MODY families. Fifteen of the mutations were novel. The variants segregated with diabetes within the families, and none of the variants were found in 100 normal Danish chromosomes. Their findings suggested a relative prevalence of 3% of MODY1 (2 different mutations in 2 families), 10% of MODY2 (7 in 8), and 36% of MODY3 (21 in 28) among Danish kindred clinically diagnosed as MODY. No significant differences in biochemical and anthropometric measurements were observed at baseline examinations. Forty-nine percent of the families carried mutations in the 3 examined MODY genes.

Pearson et al. (2007) studied 108 members of 15 families with MODY due to a mutation in the HNF4A gene and found that birth weights were significantly higher in mutation carriers (p less than 0.001), with 30 (56%) of 54 mutation-positive infants being macrosomic compared to 7 (13%) of 54 mutation-negative infants (p less than 0.001). In addition, 8 of 54 mutation-positive infants had transient hypoglycemia versus none of the 54 mutation-negative infants (p = 0.003), and inappropriate hyperinsulinemia was documented in all 3 hypoglycemic cases tested (see, e.g., 600281.0007). The authors concluded that mutations in HNF4A are associated with increased birth weight and macrosomia, and that the natural history of MODY1 includes hyperinsulinemia at birth that evolves to decreased insulin secretion and diabetes later in life.

Fanconi Renotubular Syndrome 4 with Maturity-Onset Diabetes of the Young

In a girl with Fanconi renotubular syndrome-4 with MODY (FRTS4; 616026), Stanescu et al. (2012) identified a de novo heterozygous missense mutation in the HNF4A gene (R76W; 600281.0008).

Hamilton et al. (2014) identified a heterozygous R76W mutation in 6 individuals from 4 unrelated families with FRTS4 and a pancreatic beta-cell phenotype manifest as macrosomia and neonatal hypoglycemia associated with hyperinsulinemia or MODY. Analysis of urine and serum samples from 20 diabetic patients with other HNF4A mutations showed no evidence of a Fanconi renal phenotype. Hamilton et al. (2014) concluded that this specific mutation is associated with a unique phenotype comprising both MODY and FRTS.

Penetrance of HNF4A Mutations in Diabetes

Mirshahi et al. (2022) comprehensively assessed the penetrance and prevalence of pathogenic variants in HNF1A, HNF4A, and GCK (138079) that account for more than 80% of monogenic diabetes. Mirshahi et al. (2022) analyzed clinical and genetic data from 1,742 clinically referred probands, 2,194 family members, clinically unselected individuals from a US health system-based cohort of 132,194 individuals, and a UK population-based cohort of 198,748 individuals, and found that 1 in 1,500 individuals harbor a pathogenic variant in one of these genes. The penetrance of diabetes for HNF1A and HNF4A pathogenic variants was substantially lower in the clinically unselected individuals compared to clinically referred probands and was dependent on the setting (32% in the population, 49% in the health system cohort, 86% in a family member, and 98% in probands for HNF1A). The relative risk of diabetes was similar across the clinically unselected cohorts, highlighting the role of environment/ other genetic factors. Surprisingly, the penetrance of pathogenic GCK variants was similar (89 to 97%) across all cohorts. The authors suggested that for HNF1A and HNF4A, genetic interpretation and counseling should be tailored to the setting in which a pathogenic monogenic variant was identified. GCK is an exception with near-complete penetrance in all settings.


Animal Model

To study the contribution of HNF4A to hepatic development and differentiation, Li et al. (2000) used a technique in which Hnf4a -/- mouse embryos were complemented with wildtype visceral endoderm to counteract early embryonic lethality. By histologic analyses, the authors found that specification and early development of the liver and liver morphology did not require Hnf4a. In addition, the expression of many liver genes was unaffected in these mice. However, RT-PCR analysis showed that Hnf4a -/- fetal livers failed to express a large array of genes whose expression in differentiated hepatocytes is essential for a functional hepatic parenchyma, including apolipoproteins (e.g., APOA1, 107680), metabolic proteins (e.g., aldolase B, 612724), transferrin (190000), retinol-binding protein (e.g., RBP4, 180250), and erythropoietin (133170). The lack of Hnf4a did not affect the expression of most transcription factors but did significantly reduce the levels of Hnf1a (TCF1; 142410) and the pregnane X receptor (NR1I2; 603065), suggesting that HNF4A acts upstream of at least these 2 transcription factors, which are also important in hepatocyte gene expression.

In mice with a conditional deletion of Hnf4a in pancreatic beta cells, Gupta et al. (2005) observed hyperinsulinemia in fasted and fed animals but also impaired glucose tolerance. Islet perifusion and calcium-imaging studies showed abnormal beta cell responses to stimulation by glucose and sulfonylureas, explainable in part by a 60% reduction in expression of the potassium channel subunit Kir6.2 (KCNJ11; 600937). Cotransfection assays revealed that the Kir6.2 gene is a transcriptional target of HNF4A. Gupta et al. (2005) concluded that HNF4A is required in the pancreatic beta cell for regulation of the pathway of insulin secretion dependent on the ATP-dependent potassium channel.

Pearson et al. (2007) generated mice with pancreatic beta-cell deletion of Hnf4a and observed hyperinsulinemia in utero and hyperinsulinemic hypoglycemia at birth.

Sekiya and Suzuki (2011) screened the effects of 12 candidate factors to identify 3 specific combinations of 2 transcription factors, comprising Hnf4-alpha plus Foxa1 (602294), Foxa2 (600288), or Foxa3 (602295), that can convert mouse embryonic and adult fibroblasts into cells that closely resemble hepatocytes in vitro. The induced hepatocyte-like (iHep) cells had multiple hepatocyte-specific features and reconstituted damaged hepatic tissues after transplantation.

Marable et al. (2018) generated mice with Cre-mediated deletion of Hnf4a in the nephron lineage. Hnf4a mutant mice consumed more water and excreted more urine than control mice due to reduced expression of water transporter genes in Hnf4a mutant kidneys. The urine of Hnf4a mutant mice contained more glucose and phosphate than that of controls because loss of Hnf4a resulted in the loss of glucose and phosphate transporters in proximal tubules, recapitulating a Fanconi renotubular syndrome (FRTS4; 616026)-like phenotype. In addition, adult Hnf4a mutant mice had smaller kidneys with highly disorganized and fewer proximal tubules, and displayed nephrocalcinosis resulting from calcium accumulation in renal tubules, confirming that Hnf4a mutant mice recapitulate the FRTS patient phenotype.


Evolution

To explore the evolution of gene regulation, Schmidt et al. (2010) used chromatin immunoprecipitation with high-throughput sequencing (ChIP-seq) to determine experimentally the genomewide occupancy of 2 transcription factors, CEBPA (116897) and HNF4A, in the livers of 5 vertebrates, Homo sapiens, Mus musculus, Canis familiaris, Monodelphis domesticus (short-tailed opossum), and Gallus gallus. Although each transcription factor displayed highly conserved DNA binding preferences, most binding was species-specific, and aligned binding events present in all 5 species were rare. Regions near genes with expression levels that are dependent on a transcription factor were often bound by the transcription factor in multiple species yet showed no enhanced DNA sequence constraint. Binding divergence between species can be largely explained by sequence changes to the bound motifs. Among the binding events lost in one lineage, only half are recovered by another binding event within 10 kb. Schmidt et al. (2010) concluded that their results revealed large interspecies differences in transcriptional regulation and provided insight into regulatory evolution.


ALLELIC VARIANTS 8 Selected Examples):

.0001   MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, GLN268TER
SNP: rs137853334, ClinVar: RCV000009790, RCV001659688

In the historic R-W pedigree in which Fajans (1989) defined type 1 maturity-onset diabetes of the young (125850), Yamagata et al. (1996) found a C-to-T substitution in codon 268 of the TCF14 gene that generated a CAG-to-TAG (Q268X) nonsense mutation. Some subjects in the R-W pedigree had inherited the Q268X mutation but were not yet diabetic; in addition, there were subjects in the pedigree who had noninsulin-dependent diabetes mellitus but did not inherit the Q268X mutation or at-risk haplotype. In one case, NIDDM had been diagnosed at the age of 48 years, and the patient was hyperinsulinemic, indicating that this was probably late-onset NIDDM rather than MODY. The patient had 6 children, 1 of whom also had NIDDM; another child had impaired glucose tolerance, and all had only normal alleles at the TCF14 locus.


.0002   MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, ARG154TER
SNP: rs137853335, ClinVar: RCV000009791, RCV000516683

Lindner et al. (1997) reported a second nonsense mutation in the HNF4-alpha gene in a 3-generation MODY1 (125850) pedigree, Dresden-11. A C-to-T transition resulted in an arg-to-ter mutation at codon 154 (R154X). Extensive clinical studies of 6 affected members of this family showed severe diabetes requiring insulin or oral hypoglycemic agents, but no liver or renal abnormalities. These results suggested to Lindner et al. (1997) that despite expression of HNF4-alpha in liver, kidney, intestine, and pancreas, nonsense mutations in HNF4-alpha appear to affect only pancreatic beta-cell function.

Eeckhoute et al. (2001) reported that loss of HNF4-alpha function by R154X is increased through impaired physical interaction and functional cooperation between HNF4-alpha and p300 (602700).


.0003   MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, ARG127TRP
SNP: rs137853336, gnomAD: rs137853336, ClinVar: RCV000009792, RCV000711955, RCV001375546, RCV001536085, RCV002453254, RCV003445066

In 3 of 5 members with MODY (125850) in 1 family, Furuta et al. (1997) identified an arg127-to-trp (R127W) mutation resulting from a transition from CGG to TGG. The mutation was located in the T-box, a region of the protein that may play a role in HNF-4-alpha dimerization and DNA binding. The findings in the family suggested that the R172W mutation was not the only cause of diabetes. The overall results suggested that mutations in the HNF4A gene may cause early onset NIDDM/MODY in Japanese but such mutations are less common than mutations in the HNF1A/MODY3 gene (142410).


.0004   TYPE 2 DIABETES MELLITUS

HNF4A, VAL393ILE
SNP: rs137853337, gnomAD: rs137853337, ClinVar: RCV000009793, RCV000481825, RCV002482848

In a single French family with T2D (125853) diagnosed before the age of 45 years, Hani et al. (1998) found a val393-to-ile amino acid substitution in the TCF14 gene. Expression studies showed a marked reduction of transactivation activity, a result consistent with this mutation contributing to the insulin secretory defect observed in the family.


.0005   MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, 1-BP DEL, PHE75T
ClinVar: RCV000009794

To determine the prevalence of MODY caused by HNF4-alpha mutations (MODY1; 125850), Moller et al. (1999) screened 10 Danish non-MODY3 probands for mutations in the minimal promoter and the 12 exons of the HNF4-alpha gene. One proband had a frameshift mutation (Phe75fsdelT) in exon 2 resulting in a premature termination after 117 amino acids. The authors concluded that defects in the HNF4-alpha gene are a rare cause of MODY in Denmark.


.0006   MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, IVS5, DEL A, -2
SNP: rs1600731198, ClinVar: RCV000009795, RCV003234535

In a Spanish family with MODY (125850), Barrio et al. (2002) found a deletion of an A nucleotide at the canonic acceptor splice site of exon 6. The pedigree exhibited a severe form of diabetes with a high incidence of chronic complications. The proband was diagnosed at 15 years of age. This represented the first report of a MODY1 pedigree in the Spanish population.


.0007   MATURITY-ONSET DIABETES OF THE YOUNG, TYPE 1

HNF4A, MET364ARG
SNP: rs137853338, ClinVar: RCV000009796

In affected members of a 3-generation family with MODY (125850), Pearson et al. (2007) identified heterozygosity for a 1091T-G transversion in the HNF4A gene, resulting in a met364-to-arg (M364R) substitution. A 16-year-old girl and her 15-year-old brother were macrosomic at birth and hypoglycemic in the first 24 hours of life, and the sister also had documented inappropriate hyperinsulinemia in the presence of hypoglycemia; both later developed diabetes, at 12 and 14 years of age, respectively. Their mother, maternal aunt, and maternal grandmother had developed diabetes at ages 31, 18, and 40 years, respectively.


.0008   FANCONI RENOTUBULAR SYNDROME 4, WITH MATURITY-ONSET DIABETES OF THE YOUNG

HNF4A, ARG76TRP
SNP: rs587777732, ClinVar: RCV000144170, RCV000193614, RCV000255966, RCV000763446, RCV000850560, RCV002408643

In a girl with Fanconi renotubular syndrome-4 with MODY (FRTS4; 616026), Stanescu et al. (2012) identified a de novo heterozygous c.226C-T transition in the HNF4A gene, resulting in an arg76-to-trp (R76W) substitution. Functional studies of the variant were not performed.

Hamilton et al. (2014) identified a heterozygous R76W mutation in 3 members of a family with FRTS4 and a pancreatic beta-cell phenotype manifest as macrosomia and neonatal hypoglycemia associated with hyperinsulinemia. The mutation arose in the proband's maternal grandfather, who carried the germline and somatic mosaic form of the mutation (26% mutation in leukocyte DNA). Three additional unrelated carriers of the heterozygous R76W mutation were subsequently identified from a cohort of 147 probands with HNF4A mutations; all had the Fanconi renal phenotype with nephrocalcinosis. The R76W mutation, which occurs in the DNA-binding domain, was hypothesized to cause defective interaction with major regulatory genes; however, functional studies were not performed. Hamilton et al. (2014) concluded that this specific mutation is associated with a unique phenotype comprising both MODY and FRTS.


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Contributors:
Ada Hamosh - updated : 01/17/2023
Bao Lige - updated : 07/02/2019
Bao Lige - updated : 10/02/2018
Ada Hamosh - updated : 10/3/2014
Matthew B. Gross - updated : 9/30/2014
Cassandra L. Kniffin - updated : 9/23/2014
Ada Hamosh - updated : 7/16/2013
Ada Hamosh - updated : 8/4/2011
Ada Hamosh - updated : 6/30/2010
Marla J. F. O'Neill - updated : 5/6/2008
Patricia A. Hartz - updated : 8/3/2007
John A. Phillips, III - updated : 10/19/2006
Patricia A. Hartz - updated : 7/11/2006
Marla J. F. O'Neill - updated : 7/8/2005
Ada Hamosh - updated : 6/10/2004
Patricia A. Hartz - updated : 5/7/2004
Victor A. McKusick - updated : 6/16/2003
Victor A. McKusick - updated : 1/15/2003
John A. Phillips, III - updated : 1/9/2003
John A. Phillips, III - updated : 7/12/2002
George E. Tiller - updated : 2/8/2002
Ada Hamosh - updated : 10/18/2001
John A. Phillips, III - updated : 9/25/2001
Paul J. Converse - updated : 9/5/2000
Victor A. McKusick - updated : 2/4/2000
John A. Phillips, III - updated : 11/17/1999
Victor A. McKusick - updated : 3/20/1998
Victor A. McKusick - updated : 2/24/1998
Victor A. McKusick - updated : 2/13/1998
Ada Hamosh - updated : 10/20/1997
Victor A. McKusick - updated : 2/11/1997

Creation Date:
Victor A. McKusick : 1/5/1995

Edit History:
alopez : 01/17/2023
carol : 09/02/2020
carol : 07/08/2019
mgross : 07/02/2019
alopez : 10/02/2018
joanna : 07/21/2016
carol : 07/20/2016
alopez : 07/18/2016
alopez : 3/11/2015
alopez : 10/3/2014
mgross : 9/30/2014
alopez : 9/24/2014
mcolton : 9/23/2014
ckniffin : 9/23/2014
alopez : 7/16/2013
tpirozzi : 7/12/2013
alopez : 8/15/2011
terry : 8/4/2011
alopez : 7/1/2010
alopez : 7/1/2010
terry : 6/30/2010
carol : 4/14/2009
terry : 2/19/2009
carol : 5/8/2008
terry : 5/6/2008
alopez : 8/3/2007
alopez : 10/19/2006
mgross : 7/11/2006
mgross : 7/11/2006
terry : 7/11/2006
carol : 11/18/2005
terry : 7/8/2005
alopez : 6/15/2004
terry : 6/10/2004
mgross : 5/7/2004
alopez : 7/28/2003
alopez : 6/16/2003
terry : 6/16/2003
carol : 5/28/2003
alopez : 2/28/2003
alopez : 1/15/2003
alopez : 1/9/2003
tkritzer : 12/10/2002
alopez : 7/12/2002
alopez : 7/12/2002
cwells : 2/19/2002
cwells : 2/8/2002
carol : 10/18/2001
cwells : 9/28/2001
cwells : 9/25/2001
mgross : 9/5/2000
mcapotos : 2/29/2000
mcapotos : 2/15/2000
mcapotos : 2/15/2000
terry : 2/4/2000
alopez : 11/17/1999
alopez : 11/17/1999
carol : 8/26/1998
alopez : 8/25/1998
dkim : 7/21/1998
dholmes : 4/17/1998
alopez : 3/25/1998
terry : 3/20/1998
alopez : 2/25/1998
terry : 2/24/1998
mark : 2/22/1998
terry : 2/13/1998
alopez : 12/8/1997
alopez : 11/19/1997
jamie : 5/7/1997
jenny : 3/31/1997
terry : 2/11/1997
mark : 12/4/1996
terry : 12/3/1996
mark : 12/7/1995
carol : 1/5/1995