Monogenic diabetes is a gateway to precision medicine through molecular mechanistic insight. Hepatocyte nuclear factor 1A (HNF-1A) and HNF-4A are transcription factors that engage in crossregulatory gene transcription networks to maintain glucose-stimulated insulin secretion in pancreatic β cells. Variants in the HNF1A and HNF4A genes are associated with maturity-onset diabetes of the young (MODY). Here, we explored 4 variants in the P2-HNF4A promoter region: 3 in the HNF-1A binding site and 1 close to the site, which were identified in 63 individuals from 21 families of different MODY disease registries across Europe. Our goal was to study the disease causality for these variants and to investigate diabetes mechanisms on the molecular level. We solved a crystal structure of HNF-1A bound to the P2-HNF4A promoter and established a set of techniques to probe HNF-1A binding and transcriptional activity toward different promoter variants. We used isothermal titration calorimetry, biolayer interferometry, x-ray crystallography, and transactivation assays, which revealed changes in HNF-1A binding or transcriptional activities for all 4 P2-HNF4A variants. Our results suggest distinct disease mechanisms of the promoter variants, which can be correlated with clinical phenotype, such as age of diagnosis of diabetes, and be important tools for clinical utility in precision medicine.

Clinical Chemistry and Pharmacology University Hospital Skåne Lund Sweden

Clinical Genetics Pathology and Molecular Diagnostics University Hospital Skåne Lund Sweden

Department of Biomedicine and

Department of Medical Genetics and

Department of Medical Genetics Sorbonne Université AP HP Pitié Salpêtrière Hospital DMU BioGeM Paris France

Department of Pediatrics 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Pediatrics and Adolescent Medicine Haukeland University Hospital Bergen Norway

Department of Surgery Haukeland University Hospital Bergen Norway

Exeter Genomics Laboratory Royal Devon and Exeter NHS Foundation Trust Exeter United Kingdom

Faculty of Biochemistry and Molecular Medicine and Biocenter Oulu University of Oulu Oulu Finland

Mohn Center for Diabetes Precision Medicine Department of Clinical Science University of Bergen Bergen Norway

Monogenic Diabetes Study Group of the Société Francophone du Diabète Paris France

Section of Endocrinology and Metabolism Children and Youth Clinic Haukeland University Hospital Bergen Norway

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