the patient is overweight, or gestational diabetes if the patient is pregnant. Standard diabetes treatments (insulin for type 1 and gestational diabetes, and oral hypoglycemic agents for type 2) are often initiated before the doctor suspects a more unusual form of diabetes. Pathophysiology The recognised forms of MODY are all due to ineffective insulin production or release by pancreatic beta cells. Several of the defects are mutations of transcription factor genes. One form is due to mutations of the glucokinase gene. For each form of MODY, multiple specific mutations involving different amino acid substitutions have been discovered. In some cases, there are significant differences in the activity of the mutant gene product that contribute to variations in the clinical features of the diabetes (such as degree of insulin deficiency or age of onset). Diagnosis The following characteristics suggest the possibility of a diagnosis of MODY in hyperglycemic and diabetic patients: Mild to moderate hyperglycemia (typically 130–250 mg/dL, or 7–14 mmol/L) discovered before 25 years of age. However, anyone under 50 can develop MODY. A first-degree relative with a similar degree of diabetes. Absence of positive antibodies or other autoimmunity (e.g., thyroiditis) in patient and family. However, Urbanova et al. found that about one quarter of Central European MODY patients are positive for islet cell autoantibodies (GABA and IA2A). Their expression is transient but highly prevalent. The autoantibodies were found in patients with delayed diabetes onset, and in times of insufficient diabetes control. The islet cell autoantibodies are absent in MODY in at least some populations (Japanese, Britons). Persistence of a low insulin requirement (e.g., less than 0.5 u/kg/day) past the usual "honeymoon" period. Normal insulin levels (e.g. 2.6-24.9) Absence of obesity (although overweight or obese people can get MODY) or other problems associated with type 2 diabetes or metabolic syndrome (e.g., hypertension, hyperlipidemia, polycystic ovary syndrome). Insulin resistance very rarely happens. Cystic kidney disease in patient or close relatives. Non-transient neonatal diabetes, or apparent type 1 diabetes with onset before six months of age. Liver adenoma or hepatocellular carcinoma in MODY type 3 Renal cysts, rudimentary or bicornuate uterus, vaginal aplasia, absence of the vas deferens, epidymal cysts in MODY type 5 The diagnosis of MODY is confirmed by specific gene testing available through commercial laboratories. Classification Heterozygous MODY is inherited in an autosomal dominant fashion, and most patients therefore have other members of the family with diabetes; penetrance differs