1208
The distinctive pattern of distribution of the excess
copper in the last stages of Indian childhood cirrhosis
suggests there is a genetically determined abnormality of
copper metabolism which is different from that in Wil-
son’s disease. The hepatic copper content in early stages
of Indian childhood cirrhosis must now be examined.
Supported by National Institutes of Health National Institute of En-
vironmental Health Sciences grant no. 2P30 ES00928 06; National
Institute of Arthritis, Metabolism, and Digestive Diseases grant no.
17702; and National Heart, Lung, and Blood Institute grant no.
21756.
Requests for reorints should be addressed to H. P.
REFERENCES
1. Portmann, B., Tanner, M. S., Mowat, A. P., Williams, R. Lancet, 1978, 1,
1338.
2. Tanner, M. S., Portmann, B., Mowat, A. P., Williams, R. Br. med. J. 1978,
ii, 928.
3. Salaspuro, M., Sipponen, P. Gut, 1976, 17,787.
4. Nayak, N. D., Ramalingaswami, V. Clin. Gastroenterol. 1975, 4, 333.
5. Sternlieb, I., Schemberg, I. H. New Engl. J. Med. 1968, 287, 352.
6. Committee on Medical and Biologic Effects of Environmental Pollutants.
Copper. National Academy of Sciences. Washington, D.C., 1977.
7. Smallwood, R. A., Williams, H. A., Rosenoer, V. M., Sherlock, S. Lancet,
1968, ii, 1310.
8. Irons, R. D., Schenk, E. A., Lee, J. C. K. Archs Pathol. Lab. Med. 1977,
101, 298.
9. Balasubrahmanyan, M., Chopra, H. L. Indian J. med. Sci. 1960, 14, 351.
10. Datta, D. V., Sahni, M. M., Narang, A. P. S., Sharma, J. P., Dang, H. S.,
Walia, N. S., Somasunbram, S. Indian Soc. Gastroenterol. 1978, 19, 3.
11. Sternlieb, I., Goldfischer, S. in Lysosomes in Biology and Pathology (edited
by J. T. Dingle, R. T. Dean); p. 185. Oxford, 1976.
12. Goldfischer, S., Sternlieb, I. Am.J. Path. 1968, 53, 883.
13. Baraona, E., Leo, M. A., Borowsky, S. A., Lieber, C. S. J. clin. Invest. 1977,
60, 546.
14. Franke, W. W., Denk, H., Schmid, E., Osborn, M., Weber, K. Lab. Invest.
1979, 40, 207.
15. French, S. W., Sim, J. S., Caldwell, M. G. in Membrane Alterations as Basis
of Liver Injury (edited by H. Popper, L. Bianchi, W. Reutter); p. 311.
Lancaster, 1977.
16. Denk, H., Eckertstorfer, R. Lab. Invest. 1977, 36, 563.
17. Wallin, M., Larsson, H., Edström, A. Exp. Cell Res. 1977, 107, 219.
18. Edström, A., Mattson, H. Brain Res. 1976, 108, 381.
19. McLean, W. G., Keen, P. Exp. Cell Res. 1973, 80, 345.
20. Sternlieb, I. J. Microsc. 1965, 4, 551.
GENETIC MARKER FOR
INSULIN-DEPENDENT DIABETES MELLITUS
D. RAUM C. A. ALPER
R. STEIN K. H. GABBAY
Center for Blood Research and Department of Medicine,
Children’s Hospital Medical Center, and Department of
Pediatrics, Harvard Medical School, Boston, Mass., U.S A.
Summary A rare genetic type (Bf F1) of properdin
factor B is found in 22·6% of patients
with insulin-dependent diabetes mellitus but in only
1·9% of the general population, yielding a relative risk
of 15·0. This indicates that a genetic locus for insulin-
dependent diabetes mellitus is very close on chromosome
6 to Bf, and that Bf F1 is a marker for nearly 1 out of
4 insulin-dependent diabetic patients.
Introduction
JUVENILE-ONSET insulin-dependent diabetes mellitus
(I.D.D.M.) is a common disorder with a tendency to occur
in families. Extensive investigations have failed to reveal
the mode of transmission.’ Differences in season of
onset, presence or absence of antibodies directed against
islet-cell components, and the presence or absence of late
complications suggest that I.D.D.M. is a heterogeneous
group of diseases. Onset may follow viral infection, thus
implicating the immune system in the pathogenesis.3-s
The increased risk of I.D.D.M. in families with a proband
and the 50% concordance rate of LD.D.M. for monozygo-
tic twins suggest a genetic basis for LD.D.M.6 LD.D.M. has
been associated with a high prevalence of HLA B8,
Bwl5, B18, Dw3, and Dw4, and a low prevalence of
HLA B7 and Dw2.7-9 All known genetic mechanisms for
inheritance of I.D.D.M. have been suggested. In general,
in human genetics the proof that a trait is genetic is the
demonstration of a simple mode of inheritance. The
satisfactory genetic study of diabetes has been compli-
cated by low penetrance and the inability to detect im-
penetrant carriers, making rigorous genetic analysis im-
possible.We report the detection of a rare
codominantly inherited trait which occurs in more than
20% of I.D.D.M. patients. This trait is an allele of the Bf
locus (the genetic locus for properdin factor B), and is
closely linked to the major histocompatibility complex."
This finding should facilitate detection of impenetrant
carriers and allow a thorough genetic analysis.
Materials and Methods
We analysed serum or plasma (in ethylenediaminetetraace-
tate, E.D.T.A.) from 106 White I.D.D.M. patients participating in
the Vascular Disease and Diabetes Control Study at Children’s
Hospital Medical Center and 262 randomly selected non-dia-
betic White individuals. We also studied families of 6 propositi
(three simplex and three multiplex families), the non-diabetic
siblings of 9 additional simplex propositi, and the diabetic sib-
lings of 4 additional multiplex propositi. Absence of diabetes
in family members was determined by normal levels of glyco-
sylated haemoglobins, HbA"I
Serum samples were subjected to prolonged electrophoresis
on agarose gel and subsequently immunofixed with antiserum
to properdin factor B (Atlantic Antibodies, Westbrook, Me.).
Two common alleles denoted Bf (slow) and Bf (fast) and the
rare alleles Bfl and Bf F’ were determined as previously de-
z
scribed. 12
Results
24 of 106
patients were found to carry the B1 allele
(of phenotypes, 20 were Bf SF1, two were FF1, and two
were S1F1). The gene frequencies were Bfs=0.7214,
BfF=0.1414, Bfs1=0.0236, and BfF1=0.1132. For con-
trols, the frequencies of these alleles were 0.8055,
0’1733, 0.0095, and 0.0095, respectively. The &khgr;2= (3)
comparing gene frequencies in these two populationsis
248 (P approaching zero). The control population fits
the expectations of the Hardy-Weinberg law. The devia-
tion from the Hardy-Weinberg distribution of observed
phenotypes in the I.D.D.M. population is X2 (9)=419 P
approaching zero). Since 5 individuals in the control
population carried BJFI, the relative risk of developing
I.D.D.M. in an individual carrying the BfF’ allele is
(257)x(24)/(82)x5=15.0..
That BfF’ in these children is not an artifact is indi-
, cated by the occurrence of all common alleles in com-
bination with B .fl. All 24 Bf F1 sera have been com-

PHENOTYPES OF SIBLINGS IN FAMILY STUDIES WITH A BfF1
PROBAND
pared with serum from a known non-diabetic BfF1
homozygote, confirming mobility.
Among seven pairs of diabetic siblings including one
set of identical twins, four pairs carried BfF1. In two of
the families with a proband who carried BJFI, the second
diabetic child did not carry BJFI. The accompanying
table presents family studies showing that among sib-
lings of 12 simplex cases there were 6 non-diabetic BJF1f1
individuals and 12 non-diabetic siblings who did not
carry BJF1. Among four multiplex families with a BJF1
proband, there were 3 non-diabetic siblings with BJFI, 7
non-diabetic siblings without Bfrl, and 2 diabetic
children who did not carry BJFI. The figure presents the
results of study of four families. In family Lan, the
spouse of P.You had 7 siblings with LD.D.M., and the
BfF1 allele has clearly descended from this progenitor. In
families Wyn, Cor, and Ant there was no previous his-
tory of i.D.D.M.
Four families with insulin-dependent diabetes mellitus.
Males are designated by squares, females by circles. Bf type is given
below each symbol and patients with insulin-dependent diabetes mel-
litus are shown as cross-hatched symbols. A cross indicates a deceased
family member. The diamond denotes seven deceased insulin-depen-
dent diabetic siblings.
1209
Discussion
These data argue for a diabetogenic gene (Dm) closely
linked to Bf and in linkage disequilibrium with BjF1. Bf
has been shown to be closely linked to HLA.10 The
prevalence of HLA B8 and Bwl5 is known to be in-
creased in I.D.D.M. patients, 7-9 with relative risks of
2.03-2.69 and 1 17-2.45, respectively. An even higher
incidence and relative risk of 4.5 for HLA Dw3 has been
reported.13 We have found a relative risk of 15-0 for
BjF1. In family studies, we have observed a recombina-
tion fraction of 4.1% for HLA-B and Bf14 and found
that Bf segregated with HLA-D rather than HLA-B in
an informative crossover. Others have found Bf to be
much more closely linked to HLA-B.ts-1g The present
finding of a more striking allelic association between
BfFl and Dm than that between HLA-D and Dm sup-
ports the localisation of Bf (and Dm) outside of HLA-
A,C,B,D on the HLA-D side. Given the presumed
ancient origin of I.D.D.M., the striking allelic association
of BfF1 and Dm further suggests that the genetic loci are
very close and the recombination fraction very low.
In a previous study of Bf in relation to I.D.D.M., a
modest linkage disequilibrium was noted between BfS
and I.D.D.M.9 but no mention was made of BjF1. In two
reports 19,20 dealing primarily with crossovers within
HLA, one gave Bf types only of parents, and that only
incidentally. Of the genes observed, it was clear that
BfF1and BjS1 occurred with unusually high frequency,
but this point was not discussed. The other report20
showed the presence of the two rare Bf alleles in two
families of I.D.D.M. probands, one family with BfF1 and
the other with Bfsl.
These results of family studies are consistent with Dm
being linked to BfF1, and in family Ant to BjS1. They are
also consistent with either a dominant or a recessive
mode of inheritance with incomplete penetrance in both
possibilities. If inheritance is recessive, then in family
Ant, three Bf-linked Dm genes would be present, one
linked to B/", one to Bfs1 and one to BfF, and the
mother, S. Ant, would be an impenetrant homozygote
for Dm. In the recessive model, assuming 50% pene-
trance, the Dm gene would be carried by 13% of the
general population so that impenetrant homozygotes
would be relatively common, and even more common- in
families preselected for multiple affected siblings.
The diabetogenic allele (Dm), close to Bf, exhibits a
very strong allelic association with BjF1 making possible
the detection of the carrier state and identification of a
subpopulation of l.D.D.M. This should allow definition of
the mode of inheritance, estimation of penetrance, and
analysis of linkage. If the incidence of LD.D.M. is about
0.2% in the general population and penetrance about
1/3, then for a dominant mode of inheritance about 1 in
13 individuals in the population with BjF1 will carry Dm
and, for a recessive mode of inheritance, virtually all
Bf 1 individuals will carry Dm. In either case, BjF1
promises to be an important marker for the Dm gene.
These studies should make it possible to determine the
risk that diabetes will develop in kin of affected individ-
uals. They further provide the opportunity to unravel
the mode of transmission of diabetes and its relation to
multiple genetic and environmental factors.
This work was supported by grants AI-14157, AI-13626, AM-16392,
AI-15033, AM-15019, and HL-20539 from the National Institutes of
1210

Health, grants (6-183 and 6-82) from the National Foundation-March
of Dimes, and by the Charles E. Merrill Trust. K.H.G. is an Established
Investigator of the American Heart Association.
Requests for reprints should be addressed to D. R., Center for Blood
Research, 800 Huntington Ave., Boston 02115, U.S.A.
REFERENCES
1. Neel, J. V. in the Genetics of Diabetes Mellitus (edited by W. Creutzfeldt,
J. Köbberling, and J. V. Neel). Berlin, 1975.
2. Rotter, J. I., Rimoin, D. L. Diabetes, 1978, 27, 599.
3. Gundersen, E. J. infect. Dis. 1927, 41, 197.
4. Gamble, D. R., Taylor, K. W., Cumming, H. Br. med. J. 1965, i, 960.
5. Craighead, J. E. New Engl. J. Med. 1978, 299, 1439.
6. Tattersall, R. B., Pyke, D. A. Lancet, 1972, ii, 1120.
7. Nerup, J., Platz, P., Ortved Andersen, O., Christy, M., Lyngsoe, J., Poulsen,
J. E., Ryder, L. P., Staub-Nielsen, L., Thomsen, M., Svejgaard, A. ibid.
1974, ii, 864.
8. Barbosa, J., King, R., Noreen, H., Yums, E. J. J. clin. Invest. 1977, 60, 989.
9. Cudworth, A. G. Diabetologia, 1978, 14, 281.
10. Allen, F. H. Jr. Vox Sang. 1974, 27, 382.
11. Gabbay, K. H., Hasty, K., Breslow, J. L., Ellison, R. C., Bunn, H. F., Gal-
lop, P. M. J. clin. Endocr. Metab. 1977, 44, 859.
12. Alper, C. A., Boenisch, T., Watson, L. J. exp. Med. 1972, 135, 68.
13. Thomsen, M., Platz, P., Ortved Andersen, O., Christy, M., Lyngsoe, J.,
Nerup, J., Rosmussen, N., Ryder, L. P., Staub Nielsen, L., Svejgaard, A.
Transplant. Rev. 1975, 22, 120.
14. Raum, D., Glass, D., Carpenter, C. B., Alper, C. A., Schur, P. H. J. clin.
Invest. 1976, 58, 1240.
15. Rittner, Ch., Grosse-Wilde, H., Rittner, B., Netzel, B., Scholz, S., Lorenz,
H., Albert, E. D. Humangenetik, 1975, 27, 173.
16. Teisberg, P., Olaisen, B., Gedde-Dahl, T., Jr., Thorsby, E. Tissue Antigens,
1975, 5, 257.
17. Lamm, L. U., Jørgensen, F., Kissmeyer-Nielsen, F. ibid. 1976, 7, 122.
18. Hauptmann, G., Sasportes, M., Tongio, M. M., Mayer, S., Dausset, J. ibid.
p. 52.
19. Rubinstein, P., Suciu-Foca, N., Nicholson, J. F., Fotino, M., Molinaro, A.,
Harisiadis, L., Hardy, M. A., Reemtsma, K., Allen, F. H., Jr. J. exp. Med.
1976, 143, 1277.
20. Suciu-Foca, N., Rubinstein, P. Transplant. Proc. 1977, 9, suppl. 1, p. 83.
indirect recording methods, that a hypotensive effect
persists throughout 24 h after a dose of -blocker.2 In
addition, long-term treatment has been reported to have
no effect on the variability of pressure during the day.’
These previous studies have all been done in free-rang-
ing patients and no attempt was made to standardise
conditions with regard to physical activity or sleep. We
have studied changes in blood-pressure during a range
of physical activities before and after treatment with
once-daily administration of &bgr;-adrenoceptor antagonists
in hypertensive patients under carefully standardised
conditions.
Patients and Methods
Patients
23 patients with mild to moderate essential hypertension
were studied before treatment (table I). In 17 patients observa-
tions were repeated after long-term treatment (mean 11 weeks)
with &bgr;-adrenoceptor antagonists. 5 patients had previously
received anti-hypertensive treatment, but none within a month
of study. Patients were treated with either propranolol 240 mg
(5 patients), metoprolol 200 mg (8 patients), or acebutolol 400
mg (4 patients) taken once daily between 7 A.M. and 8 A.M.
When they were studied after long-term treatment, the last
dose was taken by 8 A.M. on the day of admission. Hyperten-
sion was defined as outpatient blood-pressure recordings 140
mm Hg systolic or > 90 mm Hg diastolic pressure, on at least
three occasions. Patients with secondary hypertension or tar-
get-organ damage (ischsemic heart-disease, cerebrovascular
disease, left-ventricular hypertrophy, renal impairment, or
retinal changes greater than grade 11) were excluded.

TABLE I-DETAILS ABOUT PATIENTS AND THEIR TREATMENT

INFLUENCE OF ONCE-DAILY
ADMINISTRATION OF &bgr;-ADRENOCEPTOR
ANTAGONISTS ON ARTERIAL PRESSURE AND
ITS VARIABILITY

R. D. S. WATSON T. J. STALLARD
W. A. LITTLER
British Heart Foundation Department of Cardiovascular
Medicine, East Birmingham Hospital and University of
Birmingham

Summary Intra-arterial pressure was recorded over

24 h in hypertensive patients before and
during long-term treatment with &bgr;-adrenoceptor antag-
onists given once daily under standardised conditions.
Arterial pressure was reduced throughout the 24 h after
the last dose as was variability of pressure during physi-
cal activity; variability during sleep and rest did not
change significantly.
Introduction
RECORDING of ambulatory intra-arterial blood-pres-
sure allows detailed assessment of changes in blood-pres-
sure throughout the day and during a range of activities;
it also minimises contact with an observer. Once-daily
treatment with &bgr;-adrenoceptor antagonists has been *
Indicates patients in whom pre-treatment observations BBere made
reported to have little influence on arterial pressure dur- during periods i to iv (see text).
ing sleep or on the reported rise in pressure which occurs t p=Propranolol 240 mg daily; M=me1Oprolol 200 mg daily, A=aecbu-
between 3 A.M. and 10 A.M.;’ others have shown, with tolol 400 mg daily.