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Republic of Sudan Ministry of Higher Education and Scientific Research Shendi University Faculty of Graduate Studies and Scientific Research Molecular Identification of Genetic Markers of Susceptibility to Essential Hypertension Using Whole Exome Sequencing among Sudanese Patients from Afro- Asiatic and Nilo-Saharan ethnic groups A Thesis Submitted in Fulfillment for the Requirements of PhD Degree in Biochemistry By: Wesal Ahmed ELHanbli Babiker MBBS- MSc Medical Biochemistry Supervisor: Dr: Dina Ahmed Hassan Associate professor of Biochemistry (2020) سورة الفاتحة I Bibliographic Entry Author: Wesal Ahmed ELHanbli Babiker Thesis: Molecular Identification of Genetic Markers of Susceptibility to Essential Hypertension Using Whole Exome Sequencing among Sudanese Patients from Afro-asiatic and Nilo-Saharan ethnic groups Degree program: PhD Faculty: Faculty of Medicine Field of study: Biochemistry Supervisor: Dr: Dina Ahmed Hassan Duration: (from 2015 to 2020) Key words: Essential hypertension, whole exome sequencing, bioinformatics tools, GPCR, MTHFR, ADM, Real-time PCR. II PhD Examination Committee Members Thesis Title: Molecular Identification of Genetic Markers of Susceptibility to Essential Hypertension Using Whole Exome Sequencing among Sudanese Patients from Afro-asiatic and Nilo-Saharan ethnic groups Supervisor: Dr: Dina Ahmed Hassan Signature …………………………… date ……………………………. Internal Examiner: Prof. Rashid Eltayeb Abdalla Signature …………………………….. date …………………………… External Examiner: Prof. Mamoun Makki EL Manna Signature …………………………….. date ……………………………. III Statement I Wesal Ahmed ELHanbli Babiker, declare that the study of Molecular Identification of Genetic Markers of Susceptibility to Essential Hypertension Using Whole Exome Sequencing among Sudanese Patients from Afro-asiatic and Nilo- Saharan ethnic groups, is my own original work and submitted in fulfillment for the requirements of PhD degree in biochemistry. I have followed all ethical and technical principles in the preparation, data collection, data analysis and compilation of this study. I declare that it has not been presented to any other university for a similar or any degree award, and any sources used are indicated as references. Signature ...................................................................................... Date ……………………………………………………………… IV DEDEICATION To soul of my dear father, To my kind dear mother, To my supportive lovely little family, To my sisters and brother, To my friends, To all whom I love ,,,,, V Acknowledgments I would like to express my profound appreciation and gratitude to my supervisor Dr. Dina Ahmed Hassan Ibrahim Associate Professor of Biochemistry, director of Central Laboratory, Ministry of Higher Education and Scientific Research for her supervision and continuous encouragement and support throughout the course of this study. I would like to appreciate the contribution of both: Dr. Mutaz Amin and Dr. Mahmoud Koko for their informative knowledge and help in Bioinformatics tools. I specifically thank the two family members for their generous participation in this study. Further thanks to the patients, the healthy volunteers and all the study participants for contributing to this effort. I am grateful to all members in Central Lab with special thanks to Dr. Khalid Enan, Dalia Mursi and Raya Osman for their counseling and Kind support. My appreciation is also extended to my dear friends and colleagues in Shendi University for their continuous support. VI Abstract Background: Essential hypertension (EH) is one of most important risk factors for CVDs, stroke and end stage renal disease and a major cause of premature deaths worldwide. It is a multigene complex disorder with no known single gene playing a major role, but rather many genes each with mild effects reacting to different environmental stimuli contribute to BP. This study we hypothesized that a block of specific single nucleotide polymorphisms (SNPs) and insertion /deletion mutations (InDels) in genes controlling pathways of BP regulation is associated with susceptibility to EH among Sudanese taking the Afro-asiatic ethnic group as a model. Aim of study: To identify the genetic markers of EH among Sudanese patients. Study design: Prospective laboratory case control study Duration: (from 2015 to 2020) Site of work: Central laboratory, Ministry of Higher Education and Scientific Research. Methods and Results: Whole exome sequencing (WES) was used to analyze genomic DNA of (15) members (13 hypertensive cases and 2 normotensive controls) of two families of strong family history of EH. The 2 families belong to the Afro-asiatic ethnic group. In silico analysis and data filtration with bioinformatics tools identified set of genes which function in different metabolic pathways; mainly lipid and lipoproteins metabolism as well as signal transduction, informational and immune system pathways. Screening for MTHFR rs1801133 and ADM rs5005 was performed using real time PCR for a total of (221) samples (107 hypertensive cases and 114 VII normotensive controls). Results showed high frequency of the 2 variants among Sudanese especially among Nilo-Saharan ethnic group. Unlike ADM, MTHFR variant is associated with EH (P value 0.04) and this association is significant among females. Conclusions: WES is a molecular method used to identify novel variants associated with polygenetic complex diseases. In silico analysis applied highlighted the importance of G-protein coupled receptors (GPCRs) as an important pathway in regulating blood pressure via its role in activation of calcium release. Screening of population for the identified variants is required to determine alleles associated with susceptibility to EH and BP regulation. VIII المستخلص ارتفاع ضغط الدم اﻷساسي (EH) هو واحد من أهم عوامل الخطر ﻷمراض القلب واﻷوعية الدموية ، والسكتة الدماغية والمرض الكلوي في المرحلة النهائية وسبب رئيسي للوفاة المبكرة في جميع أنحاء العالم . إنه اضطراب معقد متعدد الجينات مع عدم وجود جين واحد معروف يلعب دو ًرا رئيسيًا ، ولكن العديد من الجينات ذات اﻵثار الخفيفة التي تتفاعل مع المنبهات البيئية المختلفة تساهم في ضغط الدم .في هذه الدراسة افترضنا أن كتلة من تعدد أشكال النوكليوتيدات الفردية (SNPs) وطفرات الحذف اﻹدراج (InDels) في الجينات التي تتحكم في مسارات تنظيم ضغط الدم ترتبط بارتفاع ضغط الدم اﻷساسي بين السودانيين وتم اخذ مجموعة عرقية أفرواسيوية كنموزج. تم استخدام تسلسل اﻹكسوم الكامل (WES) لتحليل الحمض النووي الجينومي لـ 15 عض ًوا - 13 حالة ارتفاع ضغط الدم و 2 ضوابط معيارية - لضغط الدم لعائلتين من تاريخ عائلي قوي ﻻرتفاع ضغط الدم اﻷساسي. تنتمي العائلتان إلى المجموعة اﻹثنية اﻷفرو آسيوية .حددت تصفية البيانات باستخدام أدوات المعلوماتية الحيوية مجموعة من الجينات التي تعمل في مسارات التمثيل الغذائي المختلفة ؛ بشكل رئيسي استقﻻب الدهون والبروتينات الدهنية وكذلك تحويل اﻹشارة ، ومسارات المعلومات ونظام المناعة . تم إجراء الفحص لـ MTHFR rs1801133 و ADM rs5005 باستخدام PCR في الوقت الفعلي لمجموعه 221 عينة - 107 حاﻻت ارتفاع ضغط الدم و 114 ضوابط معيارية . أظهرت النتائج توات ًرا عاليًا للمتغيرين بين السودانيين خاصة بين مجموعة النيلو الصحراوية العرقية .على عكس ADM ، يرتبط متغير MTHFRبارتفاع ضغط الدم اﻷساسي- P 0.04 - وهذا اﻻرتباط مهم خاصة عند اﻻناث. تسلسل اﻹكسوم الكامل هي طريقة جذابة لتحديد المتغيرات الجديدة المرتبطة باﻷمراض الوراثية المعقدة . يسلط تحليلنا في السليكو الضوء على أهمية المستقبﻻت المقترنة بالبروتين GPCRs) G) كمسار مهم في تنظيم ضغط الدم من خﻻل دوره في تنشيط إطﻻق الكالسيوم .مطلوب فحص السكان للمتغيرات المحددة لتحديد اﻷليﻻت المرتبطة بقابلية التأثر بالصحة وتنظيم ضغط الدم. IX Table of Contents I اﻻيه Bibliographic Entry II PhD Examination Committee Members III Statement IV Dedication V Acknowledgements VI English Abstract VII Arabic Abstract IX Table of Contents X List of Tables XIV List of Figures XVI List of Abbreviations XVII Glossary XXV CHAPTER ONE: INTRODUCTION 1.1 Definition 1 1.2 Classification 2 1.3 Pathogenesis of essential hypertension 3 1.4 Genetic role in EH 6 1.5 Methods of mapping human disease genes 6 1.6 Molecular study of hypertension in Sudan 7 1.7 Justification 9 1.8 Objectives 11 X CHAPTER TWO: LITERATURE REVIEW 2.1 Prevalence of essential hypertension 12 2.2 Genetics of hypertension 13 2.3 Clinical application of genomic sequencing to the detection of germ-line mutations 14 2.3.1 Sanger sequencing 14 2.3.2 Next generation sequencing 14 2.3.3 Whole genome sequencing 15 2.3.4 Whole exome sequencing 15 2.4 Development of genetic hypotheses in essential hypertension 16 2.4.1 Renin-angiotensin aldosterone system 17 2.4.2 G protein B3 subunit 20 2.4.3 α-adducin 21 2.4.4 Other genetic polymorphisms 22 CHAPTER THREE: MATERIALS AND METHODS 3.1 Study design 32 3.2 Study area and population 32 3.3 Inclusion criteria 32 3.4 Exclusion criteria 32 3.5 Sample size 32 3.6 Data tools 32 3.7 Study description and protocol 33 3.7.1 Phase 1: Whole exome sequencing 33 3.7.1.1 Preparation of WES sample 33 3.7.1.2 In-silico bioinformatics analysis 36 3.7.2 Phase II: Screening of the population 36 XI 3.7.2.1 DNA extraction. 36 3.7.2.2 Primer Design 37 3.7.2.3 Real-time PCR assay 37 3.8 Statistical analysis 39 3.9 Ethical consideration 39 CHAPTER FOUR: RESULTS Phase 1: Whole Exome Sequencing 4.1 Demographic characterization of the (2 ) families members 40 4.2 Whole exome sequencing results 41 4.2.1 In silico analysis 41 4.2.2 Identification of variants related to hypertension 42 4.2.3 Individual family analysis 43 4.2.4 Pathways and interactions of the selected genes 58 Phase II: Screening of the population 4.3 Case-control study results 61 4.3.1 MTHFR gene variant rs1801133 (G/A) 61 4.3.2 ADM gene variant rs5005 (C/G) 63