Robert L. Nussbaum

Genetics of Common Disorders with Complex Inheritance

Diseases such as congenital birth defects, myocardial infarction, cancer, mental illness, diabetes, and Alzheimer disease cause morbidity and premature mortality in nearly two of every three individuals during their lifetimes (Table 8-1). Many of these diseases “run in families”—they seem to recur in the relatives of affected individuals more frequently than in the general population. And yet their inheritance generally does not follow one of the mendelian patterns seen in the single-gene disorders (described in Chapter 7). Instead, they are thought to result from complex interactions between a number of genetic and environmental factors and therefore are said to follow a multifactorial (or complex) inheritance pattern. The familial clustering can be explained by recognizing that family members share a greater proportion of their genetic information and environmental exposures than do individuals chosen at random in the population. Thus, the relatives of an affected individual are more likely to experience the same gene-gene and gene-environment interactions that led to disease in the proband in the fi rst place than are individuals who are unrelated to the proband. The multifactorial inheritance pattern that results represents an interaction between the collective effect of the genotype at one or, more commonly, multiple loci (polygenic or multigenic effects) either to raise or to lower susceptibility to disease, combined with a variety of environmental exposures that may trigger, accelerate, exacerbate, or protect against the disease process. The gene-gene interactions in polygenic inheritance may be simply additive or much more complicated. For example, there may be synergistic amplifi cation of susceptibility by the genotypes at multiple loci or dampening of the effect of genotype at one locus by the genotypes at other loci. Gene-environment interactions, including systematic exposures or chance encounters with environmental factors in one’s surroundings, add even more complexity to individual disease risk and the pattern of disease inheritance. In this chapter, we fi rst address the question of how we determine that genes predispose to common diseases and, therefore, that these diseases are, at least in part, “genetic.” We describe how studies of familial aggregation, twin studies, and estimates of heritability are used by geneticists to quantify the relative contributions of genes and environment to diseases and clinically important physiological measures with complex inheritance. Second, we illustrate the general concept of gene-gene interaction, starting with one of the simplest examples, one in which modifi er genes affect the occurrence or severity of a mendelian disorder. We then give a few examples of more complicated multifactorial diseases in which knowledge of the alleles and loci that confer disease susceptibility is leading to an increased understanding of the mechanisms by which these alleles interact with each other or the environment to cause disease. Unfortunately, we do not understand the underlying mechanisms of the gene-gene and geneenvironment interactions for the majority of complex disorders. Geneticists must therefore continue to rely on empirically derived risk fi gures to give our patients and their relatives some answers to basic questions about disease risk and approaches to reducing that risk. We provide such risk fi gures here but expect that, with