Genetic architecture of type 1 diabetes with low genetic risk score informed by 41 unreported loci

Type 1 diabetes (T1D) patients with low genetic risk scores (GRS) may be non-autoimmune or autoimmune mediated by other genetic loci. The T1D-GRS2 provides us an opportunity to look into the genetic architecture of these patients. A total of 18,949 European individuals were included in this study, including 6599 T1D cases and 12,323 controls. 957 (14.5%) T1D patients were identified with low GRS (GRS < 8.43). The genome-wide association study on these patients identified 41 unreported loci. Two loci with common variants and 39 loci with rare variants were identified in this study. This study identified common SNPs associated with both low GRS T1D and expression levels of the interferon-α-induced MNDA gene, indicating the role of viral infection in T1D. Interestingly, 16 of the 41 unreported loci have been linked to autism spectrum disorder (ASD) by previous studies, suggesting that genes residing at these loci may underlie both T1D and autism. Hui-Qi Qu et al. present a case-control association study to examine the genetic architecture of European patients with type 1 diabetes (T1D) of low genetic risk score. They identify 41 loci associated with T1D of low genetic risk score, including regions previously linked to viral infection and autism spectrum disorder, altogether providing further insight into the pathogenesis of T1D.

T ype 1 diabetes (T1D) has been traditionally recognized as an autoimmune disease, and its molecular immunological mechanisms have been corroborated by the discovery of numerous autoimmune disease genes underlying the genetic susceptibility of T1D [1][2][3] . As we showed in a recent study 4 , the genetic risk of T1D can be predicted by genome-wide DNA variants generated using a global polygenic risk scoring (PRS) approach 5 . In contrast, Sharp et al. developed a specific genetic risk scoring (GRS) system for T1D, (T1D-GRS2), using 67 single nucleotide polymorphisms (SNPs) from known autoimmune loci associated with T1D, while haplotypic effects and interactions of common human leukocyte antigen (HLA) DR-DQ haplotypes, conferring the primary effects to T1D susceptibility 1,6-8 , were also taken into account 9 . In contrast to global PRS scoring using genome-wide DNA markers, T1D-GRS2 uses a small set of T1D genetic markers. Among the 67 SNPs, 35 are from the major T1D susceptibility loci, i.e., the HLA region accounting for about 50% of the genetic susceptibility in the European population 1 . The other 32 SNPs are from 31 non-HLA T1D susceptibility loci.
T1D is a complex and heterogeneous phenotype. A minor proportion (~5-10%) of Caucasian patients diagnosed with T1D have non-autoimmune pathogenesis, i.e., T1bD 10 . Moreover, there are also autoimmune patients (e.g., with islet cell autoantibodies), but with low-risk genotypes of known T1D genes, e.g., protective HLA haplotypes 11 . The PRS approach using genome-wide DNA markers represents primarily autoimmune T1D 4 , whereas low PRS suggests non-autoimmune mechanisms may be involved. As expected, a number of loci identified in our analysis have been reported of association with obesity-related traits by previous GWA studies 4 . Our gene-based association study in patients with low PRS identified the Notch ligand Deltalike 1 gene (DLL1) 12 , involved in impaired glucose tolerance and reduced insulin secretion 13 . In contrast, low GRS may also include autoimmune patients with undetermined genetic mechanisms. Thus, patients with T1D and low GRS may have their disease susceptibility conferred by other unknown genetic loci. Due to these potentially distinct biological mechanisms underlying T1D captured by PRS vs. GRS, respectively, the T1D-GRS2 scoring system provides us a unique opportunity to identify patients with low GRS and consequently enables us to look into the genetic architecture of this group of patients.

Results
GRS scores. As shown by our ROC analysis, the GRS scores for T1D prediction have the performance of the Area Under the ROC Curve (AUC) = 0.866. The cutoff of GRS = 8.43 has the maximum Matthews correlation coefficient (MCC) of 0.580, with the sensitivity to identify T1D patients (true positive rate, TPR) of 0.855 and the specificity to identify individuals without T1D (true negative rate, TNR) of 0.719 (Supplementary Data 2). We identified 957 (14.5%) T1D patients with GRS < 8. 43.
In this study, the GRS scores are significantly correlated with the PRS scores (P < 1E − 200), with Pearson's r = 0.305 and 0.331, respectively in the two PRS cohorts, as we reported 4  GWAS of T1D patients with low GRS. Nine hundred and fiftyseven T1D patients (474 males and 483 females) were identified with low GRS. The HLA loci contributed significantly to this GRS classification (Table 1), while the HLA-DQ locus contributes more to the classification (beta = 0.489) than the combined effects of other HLA loci (beta = 0.308). The GWAS results of patients with low T1D GRS vs. all non-diabetes controls (Fig. 1a) were compared with that of all T1D patients vs. all non-diabetes controls (Fig. 1b). As expected, the majority of SNPs showing genome-wide significance in low T1D GRS were also significant in the overall T1D cohort (Supplementary Data 3), which is in keeping with our original hypothesis that low GRS cases may also be driven by autoimmune mechanisms. However, the potential undetermined genetic mechanisms of the low T1D GRS patients are highlighted by 82 single nucleotide variants (SNV) from 47 non-HLA genetic loci with genome-wide significance in the low GRS T1D cases only, but not significant in the overall T1D cohort (Supplementary Data 4). The minor alleles of 81 out of the 82 SNVs are predisposing, except the SNP rs62425513 at the THE-MIS locus. Without exception, however, the genetic effects represented by these SNPs in the low GRS T1D cases are all greater than the effects observed in the overall T1D cohort, where each SNP's OR in the overall T1D cohort fell outside the 95% confidence interval (95% CI) in the low GRS T1D cohort, although 11 SNVs from 8 loci have the two-tailed P values of heterogeneity test >0.05. Unreported loci with rare variants associated with low GRS T1D. Among the 42 independent loci with rare variants (MAF < 0.050), one locus (i.e., the PGM1 locus) has been reported of association with T1D by previous GWAS studies (Supplementary Data 5, GWAS Catalog, https://www.ebi.ac.uk/gwas/) and two recent large-scale T1D GWAS 14,15 , thus was not taken as an unreported locus. In addition, the DOK6 locus identified in this study, led by the SNV rs146427450 with OR(95% CI) = 2.858  14 Besides these 3 loci and the above loci with common genetic variants associated with low GRS T1D, we uncovered 39 unreported loci with variants in the low to rare frequency range (MAF ≤ 3.92% in this study) associated with low GRS T1D (Supplementary Data 4).

Discussion
Five loci with common variants were identified of association with low GRS T1D in this study with genome-wide significance.
Besides the above 2 loci with common variants, 3 SNPs from 3 different loci (MIR4278/MIR4454, THEMIS, MSRB3) have also common SNPs with minor allele frequencies (MAF) > 0.050 associated with low GRS T1D (Figs. 4a, 5a, 6a), but not the general T1D cases (Figs. 4b, 5b, 6b). However, as shown in Figs. 4-6, different SNPs at each loci are associated with the general T1D cases, therefore these 3 loci were not taken as unreported loci specifically associated with low GRS T1D in this study. In addition, the THEMIS locus tagged by the SNP rs62425513 with OR (95% CI) = 0.673(0.584,0.775), P = 3.76E − 08, was identified of T1D association with FDR < 0.01 by Robertson, et al. 15 . Interestingly, each of these 3 loci has been identified of association with obesity-related traits or waist-hip ratio by the previous GWASs (Supplementary Data 5). The THEMIS locus was also reported of association with celiac disease by the previous GWAS 16 .
The unreported T1D genetic locus MNDA is involved in interferon signaling. At the OR6N2/MNDA/PYHIN1 locus, the strongest association signal rs857786 with OR(95% CI) = 1.322 (1.203,1.452), P = 6.44E − 09, at the 5′-upstream of MNDA, is also associated with the gene expression of MNDA in whole blood  19,20 . Interferon-α is a potential link of viral infection and autoimmunity in T1D 21 . In our study, significant association from the interferon-α-induced MNDA locus is only seen in low GRS cases, but not in overall T1D cases (Fig. 2). This may imply a plausible explanation about the pathogenesis of low GRS T1D patients, i.e., that viral infection contributes to the T1D pathogenesis in these patients despite the low overall genetic risk. In addition to our study, a previous study has shown an association of this locus with monocyte chemoattractant protein-1 levels 22 .
The unreported T1D genetic locus LINC02516/ANKRD50 is involved in retromer function. ANKRD50 has been demonstrated of essential role in the function of retromer and the endocytic recycling 23 . The protein encoded by ANKRD50 is an essential component for the retromer function 23 . The retromer mediates the retrograde transport from the endosome to the Golgi 24 . The retromer protein VPS35 which mediates the retromer cargo selection has been shown to be associated with T2D in a previous GWAS study 25 . The gene encoding a receptor of VPS35, the sortilin related VPS10 domain-containing receptor 1 gene (SorCS1), has also been reported in association with glycemic control in T1D 26 and insulin secretion in T2D 27 .
Association between autism and T1D has been reported previously 28 . Interestingly, 15 of the 39 unreported loci identified of genome-wide significance in this study have been reported to harbor variants predisposing to autism or autism spectrum disorder (ASD) according to the HGMD database (http://www. hgmd.cf.ac.uk) (Supplementary Data 4), and 2 of these loci have been previously reported of association with ASD by the previous GWASs 29,30 . Six genes at these loci are expressed at the cell synapse (cellular_component GO:0045202), including ankyrin 3 (ANK3), cell cycle associated protein 1 (CAPRIN1), cadherin 8 (CDH8), fibroblast growth factor receptor 2 (FGFR2), olfactomedin 3 (OLFM3), and prion protein (PRNP). Mechanisms of neural control of the endocrine pancreas 31 mediated by these genes are therefore highlighted. Besides the 15 loci linked to autism or ASD, two other loci with rare variants associated with low GRS T1D encode synapse-expressed genes, abhydrolase domain containing 17B (ABHD17B) and leucine-rich repeat and fibronectin type III domain containing 3 (LRFN3). It is also worth mentioning that, at the OR6N2/MNDA/PYHIN1 locus with common SNPs associated with low GRS T1D, the pyrin and HIN domain family member 1 gene (PYHIN1) whose expression is also interferon-induced has also been linked to autism and ASD by the previous study 32 .
The SNV rs148505224 associated with low GRS T1D maps to the CF transmembrane conductance regulator (CFTR) gene, i.e., the gene mutated in cystic fibrosis(CF) and a cause of pancreatitis. As this CFTR locus is close to the ASZ1 locus recently identified by Crouch et al. 14 , it is not counted as an unreported locus identified in this study. The chr4p15.2 locus encoding the peroxisome proliferator-activated receptor gamma (PPAR-γ) coactivator 1 alpha gene (PPARGC1A), which has been shown to important roles in energy homeostasis 33 . Besides the 3 loci with common SNPs associated with waist-to-hip ratio or obesityrelated traits, 8 genetic regions with rare variants demonstrating an association with low GRS T1D have been previously reported in association with body mass index (BMI), weight, waist-hip ratio, or obesity-related traits (Supplementary Data 5).
In addition to the MNDA locus, two loci have been reported of association with severe influenza A (H1N1) infection, including the locus at chr2q14.1 encoding the dipeptidyl peptidase like 10 genes (DPP10) and the locus at chr19q13.12 containing the nuclear factor kappa B (NF-κB) inhibitor delta gene (NFKBID) 34 . NFKBID is critical for B cell development as shown in mouse model 35 . In addition to the association of THEMIS with celiac disease, two loci with rare variants have been reported of association with autoimmune diseases, i.e., the long intergenic nonprotein coding RNA 1967 (LINC01967) and C-X9-C motif containing 1 (CMC1) locus at chr3p24.1 has been reported to be associated with multiple sclerosis 36 , and the small nucleolar RNA, C/D box 3F (SNORD3F)/leucine zipper tumor suppressor 1 (LZTS1) antisense RNA 1 (LZTS1-AS1) locus at chr8p21.3 which has been reported to be associated with rheumatoid arthritis 37 .
In conclusion, this study identified 41 unreported loci associated with low GRS T1D. In addition to our previous study on low PRS T1D which identified new non-autoimmune T1D loci 4 , this study identified common genetic variants at two loci related to interferon signaling involved in viral infection and retromer function, respectively. The role of viral infection in low GRS T1D is supported by the common SNPs associated with low GRS T1D inferring considerable effect size (OR~1.32). Likewise, unreported loci related to pancreatitis, BMI, and obesity were also uncovered. 16 of 41 loci have been previously linked to autism or ASD 38,39 (http://www.hgmd.cf.ac.uk). Accordingly, this study highlights a number of genes that may mediate shared molecular mechanisms of ASD and T1D. From the molecular genetics aspect, these rare variants may suggest a possibility of rare syndromic types of disease with clinical characterizations of both ASD and T1D not previously identified. Additional studies are needed to confirm our hypothesis and preliminary results, that patients with both ASD and T1D diagnosis may share common genetic factors. Patients with low T1D GRS may also be autoimmune, i.e., T1aD with undetermined genetic mechanisms, or non-autoimmune, e.g., T1bD. Among the genetic loci identified in this study, 3 loci with common SNPs and 8 genetic regions with rare variants have been previously reported in association with BMI, waist-to-hip ratio, or obesity-related traits, suggesting T1bD. It is also worth pointing out that these reported variants may still be autoimmune T1D loci, suggested by the two loci reported of association with autoimmune diseases, and the two loci associated with severe influenza A infection. Patients with low T1D GRS, whether they are T1aD or not, may have their disease susceptibility conferred by these loci with inflated effect sizes in this subgroup of patients.

Methods
Subjects. A total of 18,949 European individuals were included in this study, including 6599 T1D cases and 12,323 controls. The T1D cases were from Montreal Children's Hospital and the Children's Hospital of Philadelphia (CHOP) 3   Interventions and Complications (DCCT-EDIC) cohort (http://www.ncbi.nlm.nih. gov/projects/gap/cgi-bin/study.cgi?study_id=phs000086.v2.p1), and the Type 1 Diabetes Genetics Consortium (T1DGC, http://www.ncbi.nlm.nih.gov/projects/ gap/cgi-bin/study.cgi?study_id=phs000180.v1.p1), respectively. Informed consent was obtained from each of the relevant cohorts/studies. The genotyping was done by the Illumina Genotyping BeadChips with at least 550,000 SNPs genotyped. More details of these research subjects are previously described 3,40 . All the research subjects have been confirmed of European ancestry by principal component analysis (PCA) with genomic DNA markers. Genome-wide imputation was done by the TOPMed Imputation Server (https://imputation.biodatacatalyst.nhlbi.nih.gov) with the TOPMed (Version R2 on GRC38) Reference Panel.
GRS scoring. The GRS scoring was based on the method developed by Sharp et al. 9 . To acquire the genotype information of all the T1D-GRS2 SNPs (67 SNP markers, Supplementary Data 1), the HLA region was additionally imputed by the SNP2HLA software 41 . The overlapped SNPs covered across the imputation methods were highly consistent. Consequently, the GRS scores were assessed for their predictive performance by AUC. The GRS cutoff for low GRS vs. high GRS was determined by the maximum MCC, which represents a balanced measure of sensitivity and specificity.
Statistics and reproducibility. We tested 104,689,647 autosomal SNV with quality filters of R 2 ≥ 0.3 for the genetic association, using 12,323 controls (6665 males and 5658 females) and 6599 T1D cases, including 957 T1D patients (474 males and 483 females) with low GRS. Genetic association tests were performed using PLINK1.9 software 42 , conditioned on sex, and corrected by the first 10 principal components (PC) of population structure analysis. Genome-wide significance was defined as P < 5 × 10 −8 . The Manhattan plots were done using the SNPEVG software 43 . Genetic association signals within each locus were plotted by LocusZoom 44 . The genetic association of T1D patients with low GRS was compared with that of the general T1D patients by heterogeneity Z test 45 . We defined each locus by r 2 > 0.5 from lead SNPs 46 .
Reporting summary. Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability
Summary statistics are presented in Supplementary Data 4 and are available at the NHGRI-EBI GWAS catalog (GCP ID: GCP000182, https://www.ebi.ac.uk/gwas). The original genotyping data are available from dbGAP. All data generated or analyzed during this study are included in this published article (and its supplementary information files).