Patient Report

1 Patient Report Specimen ID: 331-883-9001-0 Acct #: 90071835 Phone: (818) 880-8040 Rte: 00 Control ID: ESOTERIX IN-HOUSE TESTING SAMPLE REPORT, NORMAL 4301 LOST HILLS RD

CALABASAS CA 91301

Patient Details Specimen Details Physician Details DOB: 01/01/2010 Date collected: 11/27/2019 0000 Local Ordering: Age(y/m/d): 009/10/26 Date received: 11/27/2019 Referring: Gender: F SSN: Date entered: 11/27/2019 ID: Patient ID: Date reported: 12/04/2019 0000 ET NPI:

Ordered Items MODY Genetic Profile TESTS RESULT FLAG UNITS REFERENCE INTERVAL LAB MODY Genetic Profile MODY Genetic Profile 01 Maturity onset diabetes of the young (MODY) is a suspected diagnosis in young non-obese patients who lack an auto-immune cause for diabetes and who have a family history of diabetes in successive generations. The majority of MODY cases are due to pathogenic variants in one of four genes (ADA Guidelines 2019, PMID 30559228). Identifying a pathogenic variant in one of these MODY genes can lead to improved treatment, increased surveillance for related symptoms, and earlier detection in currently asymptomatic family members. GCK encodes the enzyme glucokinase, a key regulator of glucose metabolism in pancreatic beta cells. The three HNF (hepatic nuclear factor) genes encode transcription factors that regulate gene expression in the pancreas.

MODY # Gene Chromosome RefSeq Transcript location (Gene) MODY 3 HNF1A 12q24.31 NG_011731.2 NM_000545.6 MODY 1 HNF4A 20q13.12 NG_009818.1 NM_175914.4 MODY 5 HNF1B 17q12 NG_013019.2 NM_000458.3 MODY 2 GCK 7p13 NG_008847.2 NM_000162.5

Preauthorization 01 Result 01 No clinically significant sequence or copy number variants were detected. Interpretation 01 No pathogenic variants or variants of uncertain clinical significance were detected by full gene sequencing or deletion/duplication analysis for any of the genes tested in this panel. Comments 01 This result decreases the likelihood that this individual has a mutation in one of the four MODY genes tested in this assay, but does not exclude the possibility that this individual has a pathogenic variant in another gene or gene region not analyzed in this assay. This result should be

Date Issued: 12/04/19 1919 ET FINAL REPORT Page 1 of 3

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1 Patient Report

Patient: SAMPLE REPORT, NORMAL Specimen ID: 331-883-9001-0 DOB: 01/01/2010 Patient ID: Control ID: Date collected: 11/27/2019 0000 Local

TESTS RESULT FLAG UNITS REFERENCE INTERVAL LAB interpreted in the context of clinical findings, family history, and other laboratory testing. As with all PCR tests, the possibility cannot be ruled out that a rare polymorphism or unusual variant alters amplification and leads to a false negative result. Genetic counseling is recommended. Additional Comments 01 If testing was performed due to a family history of MODY, genetic testing of an affected family member could allow more accurate risk assessment. Methods and Limitations 01 Analysis is performed using bidirectional Sanger sequencing of the exons and splice junctions for each gene analyzed. Copy number variants (CNVs) are detected by semi-quantitative PCR. Analytical sensitivity is estimated to be >99% for single nucleotide variants and small insertions/deletions, while clinical sensitivity can vary with the selection criteria and is predicted to be at least 85% (Colclough, PMID 24518839; Ellard, PMID 17828387). Variant classification is consistent with ACMG standards and guidelines (Richards, PMID 25741868). A variant of uncertain significance (VUS) is a classification based on inadequate or conflicting evidence and should not be used in clinical decision making. This assay reports pathogenic or likely pathogenic variants and VUS's, and benign or likely benign variants are not reported. Numbering and nomenclature use the recommendations of the Human Genome Variation Society (http://www.hgvs.org) and the transcript versions listed above.

This analysis does not detect germline mosaicism, large chromosomal rearrangements that do not alter copy number, and regions or genes not included in this test. Variant classification and/or interpretation may change over time if more information becomes available. False positive or negative results may occur for reasons that include: genetic variants that affect the assay, blood transfusions, mosaicism, mislabeled samples, or erroneous representation of family relationships.

This test was developed and its performance characteristics determined by LabCorp. It has not been cleared or approved by the Food and Drug Administration.

Date Issued: 12/04/19 1919 ET FINAL REPORT Page 2 of 3

1 Patient Report

Patient: SAMPLE REPORT, NORMAL Specimen ID: 331-883-9001-0 DOB: 01/01/2010 Patient ID: Control ID: Date collected: 11/27/2019 0000 Local

TESTS RESULT FLAG UNITS REFERENCE INTERVAL LAB PMID 17828387 3. Ellard S and Colclough K. Mutations in the genes encoding the transcription factors hepatocyte nuclear factor 1 alpha (HNF1A) and 4 alpha (HNF4A) in maturity-onset diabetes of the young. Hum Mutat 27(9): 854-69, 2006. PMID 16917892 4. Gloyn AL. Glucokinase (GCK) mutations in hyper- and hypoglycemia: maturity-onset diabetes of the young, permanent neonatal diabetes, and hyperinsulinemia of infancy. Hum Mutat 22(5): 353-62, 2003. PMID 14517946 5. Hattersley AT and Patel KA. Precision diabetes: learning from monogenic diabetes. Diabetologia 60(5): 769-77, 2017. PMID 28314945 6. Osbak KK et al. Update on mutations in glucokinase (GCK), which cause maturity-onset diabetes of the young, permanent neonatal diabetes, and hyperinsulinemic hypoglycemia. Hum Mutat 30(11): 1512-26, 2009. PMID 19790256

This case has been reviewed, approved, interpreted and electronically signed by Toni R. Prezant, PhD.

01 ES Esoterix Inc Dir: Samuel Pepkowitz, MD 4301 Lost Hills Road, Calabasas Hills, CA 91301-5358 For inquiries, the physician may contact Branch: 800-859-6046 Lab: 888-690-3935

Date Issued: 12/04/19 1919 ET FINAL REPORT Page 3 of 3

1 Patient Report Specimen ID: 331-883-9002-0 Acct #: 90071835 Phone: (818) 880-8040 Rte: 00 Control ID: ESOTERIX IN-HOUSE TESTING SAMPLE REPORT, ABNORMAL 4301 LOST HILLS RD

CALABASAS CA 91301

Patient Details Specimen Details Physician Details DOB: 01/01/2010 Date collected: 11/27/2019 0000 Local Ordering: Age(y/m/d): 009/10/26 Date received: 11/27/2019 Referring: Gender: M SSN: Date entered: 11/27/2019 ID: Patient ID: Date reported: 12/04/2019 0000 ET NPI:

Preauthorization 01 Result 01 Pathogenic variant detected

GENE: HNF1A VARIANT: c.872dupC (p.G292fs, legacy nomenclature: P291fs)

No additional sequence or copy number variants of clinical significance were detected for any of the genes tested in this panel. Interpretation 01 A heterozygous DNA sequence change (present in one copy) was detected in this individual. The insertion of a C nucleotide at position c.872 in exon 4 of the HNF1A gene (c.872dupC) is the most common pathogenic mutation in

Date Issued: 12/04/19 1921 ET FINAL REPORT Page 1 of 4

1 Patient Report

Patient: SAMPLE REPORT, ABNORMAL Specimen ID: 331-883-9002-0 DOB: 01/01/2010 Patient ID: Control ID: Date collected: 11/27/2019 0000 Local

TESTS RESULT FLAG UNITS REFERENCE INTERVAL LAB HNF1A-MODY and is expected to result in a frameshift beginning after the proline (P) at codon 291 of the HNF1-alpha protein. Although the first altered amino acid is glycine (G) in codon 292 (p.G292fs), the variant is historically referred to as P291fs or P291fsinsC. Frameshift mutations have significant effect on protein structure and are usually pathogenic. (Ellard, PMID 16917892; Yamagata, PMID 8945470; Frayling, PMID 9075818). Comments 01 HNF1A (Hepatic Nuclear Factor 1A; OMIM 142410) encodes a transcription factor required for the expression of several pancreatic- and liver- specific genes, binding its target sequences as a homodimer or as a heterodimer with HNF1-beta. The haploinsufficiency caused by heterozygous HNF1A mutations results in maturity onset diabetes of the young type 3 (MODY3). Some MODY3 families also develop hepatic adenomas when a second pathogenic variant occurs in the other gene copy, so liver screening is recommended. Earlier onset of diabetes is correlated with a maternally transmitted HNF1A mutation, likely due to effects of maternal diabetes during pregnancy, and with missense mutations located in the first seven exons, since these are expressed in all three transcripts generated by alternative splicing (Ellard, PMID 16917892; Harries, PMID 16760222; Reznik, PMID 15001650; Stride, PMID 12453975). Additional Comments 01 The identified variant has a known association with monogenic diabetes, an autosomal dominant disorder. These results should be interpreted in the context of this individual's clinical and family histories. Absence of family history does not necessarily rule out the possibility of hereditary monogenic diabetes for this individual. Testing for this mutation can be offered to appropriate, at-risk family members (Please contact the laboratory for information). As with all PCR tests, the possibility cannot be ruled out that a rare polymorphism or unusual variant alters amplification and leads to a false negative result for the other genes in this assay. Variants located in the non-analyzed regions of the four MODY genes will not be detected. Genetic counseling is recommended. Methods and Limitations 01 Analysis is performed using bidirectional Sanger sequencing of the exons and splice junctions for each gene analyzed. Copy number variants (CNVs) are detected by semi-quantitative PCR. Analytical sensitivity is estimated to be >99% for single nucleotide variants and small insertions/deletions, while clinical sensitivity can vary with the selection criteria and is predicted to be at least 85% (Colclough, PMID 24518839; Ellard, PMID 17828387). Variant classification is consistent with ACMG standards and guidelines (Richards, PMID 25741868). A variant of uncertain significance (VUS) is a classification based on

Date Issued: 12/04/19 1921 ET FINAL REPORT Page 2 of 4

1 Patient Report

Patient: SAMPLE REPORT, ABNORMAL Specimen ID: 331-883-9002-0 DOB: 01/01/2010 Patient ID: Control ID: Date collected: 11/27/2019 0000 Local

TESTS RESULT FLAG UNITS REFERENCE INTERVAL LAB inadequate or conflicting evidence and should not be used in clinical decision making. This assay reports pathogenic or likely pathogenic variants and VUS's, and benign or likely benign variants are not reported. Numbering and nomenclature use the recommendations of the Human Genome Variation Society (http://www.hgvs.org) and the transcript versions listed above.

This test was developed and its performance characteristics determined by LabCorp. It has not been cleared or approved by the Food and Drug Administration.

References 01 1. Bellanne-Chantelot C et al. Large genomic rearrangements in the hepatocyte nuclear factor-1beta (TCF2) gene are the most frequent cause of maturity-onset diabetes of the young type 5. Diabetes 54(11): 3126-32, 2005. PMID 16249435 2. Ellard S et al. Partial and whole gene deletion mutations of the GCK and HNF1A genes in maturity-onset diabetes of the young. Diabetologia 50(11) : 2313-17, 2007. PMID 17828387 3. Ellard S and Colclough K. Mutations in the genes encoding the transcription factors hepatocyte nuclear factor 1 alpha (HNF1A) and 4 alpha (HNF4A) in maturity-onset diabetes of the young. Hum Mutat 27(9): 854-69, 2006. PMID 16917892 4. Gloyn AL. Glucokinase (GCK) mutations in hyper- and hypoglycemia: maturity-onset diabetes of the young, permanent neonatal diabetes, and hyperinsulinemia of infancy. Hum Mutat 22(5): 353-62, 2003. PMID 14517946 5. Hattersley AT and Patel KA. Precision diabetes: learning from monogenic diabetes. Diabetologia 60(5): 769-77, 2017. PMID 28314945 6. Osbak KK et al. Update on mutations in glucokinase (GCK), which cause maturity-onset diabetes of the young, permanent neonatal diabetes, and hyperinsulinemic hypoglycemia. Hum Mutat 30(11): 1512-26, 2009. PMID 19790256

This case has been reviewed, approved, interpreted and electronically signed by Toni R. Prezant, PhD.

Date Issued: 12/04/19 1921 ET FINAL REPORT Page 3 of 4

1 Patient Report

Patient: SAMPLE REPORT, ABNORMAL Specimen ID: 331-883-9002-0 DOB: 01/01/2010 Patient ID: Control ID: Date collected: 11/27/2019 0000 Local

01 ES Esoterix Inc Dir: Samuel Pepkowitz, MD 4301 Lost Hills Road, Calabasas Hills, CA 91301-5358 For inquiries, the physician may contact Branch: 800-859-6046 Lab: 888-690-3935

Date Issued: 12/04/19 1921 ET FINAL REPORT Page 4 of 4