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Pode-Shakked N, Slack M, Sundaram N, Schreiber R, McCracken KW, Dekel B, Helmrath M, Kopan R. RAAS-deficient organoids indicate delayed angiogenesis as a possible cause for autosomal recessive renal tubular dysgenesis. Nat Commun 2023; 14:8159. [PMID: 38071212 PMCID: PMC10710424 DOI: 10.1038/s41467-023-43795-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023] Open
Abstract
Autosomal Recessive Renal Tubular Dysgenesis (AR-RTD) is a fatal genetic disorder characterized by complete absence or severe depletion of proximal tubules (PT) in patients harboring pathogenic variants in genes involved in the Renin-Angiotensin-Aldosterone System. To uncover the pathomechanism of AR-RTD, differentiation of ACE-/- and AGTR1-/- induced pluripotent stem cells (iPSCs) and AR-RTD patient-derived iPSCs into kidney organoids is leveraged. Comprehensive marker analyses show that both mutant and control organoids generate indistinguishable PT in vitro under normoxic (21% O2) or hypoxic (2% O2) conditions. Fully differentiated (d24) AGTR1-/- and control organoids transplanted under the kidney capsule of immunodeficient mice engraft and mature well, as do renal vesicle stage (d14) control organoids. By contrast, d14 AGTR1-/- organoids fail to engraft due to insufficient pro-angiogenic VEGF-A expression. Notably, growth under hypoxic conditions induces VEGF-A expression and rescues engraftment of AGTR1-/- organoids at d14, as does ectopic expression of VEGF-A. We propose that PT dysgenesis in AR-RTD is primarily a non-autonomous consequence of delayed angiogenesis, starving PT at a critical time in their development.
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Affiliation(s)
- Naomi Pode-Shakked
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Megan Slack
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Nambirajan Sundaram
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Ruth Schreiber
- Department of Pediatrics, Soroka University Medical Center, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Kyle W McCracken
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Benjamin Dekel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Stem Cell Research Institute and division of pediatric nephrology, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat-Gan, Israel
| | - Michael Helmrath
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA
| | - Raphael Kopan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, 45229, USA.
- Division of Developmental Biology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, 45229, USA.
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2
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Vincent KM, Alrajhi A, Lazier J, Bonin B, Lawrence S, Weiler G, Armour CM. Expanding the clinical spectrum of autosomal-recessive renal tubular dysgenesis: Two siblings with neonatal survival and review of the literature. Mol Genet Genomic Med 2022; 10:e1920. [PMID: 35286024 PMCID: PMC9034669 DOI: 10.1002/mgg3.1920] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 01/23/2023] Open
Abstract
Background Autosomal‐recessive renal tubular dysgenesis (AR‐RTD) is a rare genetic disorder caused by defects in the renin‐angiotensin system that manifests as fetal anuria leading to oligohydramnios and Potter sequence. Although the most common outcome is neonatal death from renal failure, pulmonary hypoplasia, and/or refractory arterial hypotension; several cases have been reported that describe survival past the neonatal period. Methods Herein, we report the first family with biallelic ACE variants and more than one affected child surviving past the neonatal period, as well as provide a review of the previously reported 18 cases with better outcomes. Results While both siblings with identical compound heterozygous ACE variants have received different treatments, neither required renal replacement therapy. We show that both vasopressin and fludrocortisone in the neonatal period may provide survival advantages, though outcomes may also be dependent on the type of gene variant, as well as other factors. Conclusion While AR‐RTD is most often a lethal disease in the neonatal period, it is not universally so. A better understanding of the factors affecting survival will help to guide prognostication and medical decision‐making.
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Affiliation(s)
- Krista M Vincent
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada
| | - Afrah Alrajhi
- University of Ottawa, Ottawa, Ontario, Canada.,Department of Obstetrics and Gynecology, Ottawa General Hospital, Ottawa, Ontario, Canada
| | - Joanna Lazier
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,University of Ottawa, Ottawa, Ontario, Canada
| | - Brigitte Bonin
- University of Ottawa, Ottawa, Ontario, Canada.,Department of Obstetrics and Gynecology, Ottawa General Hospital, Ottawa, Ontario, Canada
| | - Sarah Lawrence
- Division of Endocrinology and Metabolism, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Gabrielle Weiler
- University of Ottawa, Ottawa, Ontario, Canada.,Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Christine M Armour
- Department of Medical Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Prenatal Screening Ontario (PSO), Better Outcomes Registry & Network (BORN) Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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3
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Tseng MH, Huang SM, Konrad M, Huang JL, Shaw SW, Tian YC, Chueh HY, Fan WL, Wu TW, Ding JJ, Chiang MC, Lin SH. Effect of Hydrocortisone on Angiotensinogen ( AGT) Mutation-Causing Autosomal Recessive Renal Tubular Dysgenesis. Cells 2021; 10:cells10040782. [PMID: 33916187 PMCID: PMC8065467 DOI: 10.3390/cells10040782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/22/2021] [Accepted: 03/29/2021] [Indexed: 11/16/2022] Open
Abstract
We has identified a founder homozygous E3_E4 del: 2870 bp deletion + 9 bp insertion in AGT gene encoding angiotensinogen responsible for autosomal recessive renal tubular dysgenesis (ARRTD) with nearly-fatal outcome. High-dose hydrocortisone therapy successfully rescued one patient with an increased serum Angiotensinogen (AGT), Ang I, and Ang II levels. The pathogenesis of ARRTD caused by this AGT mutation and the potential therapeutic effect of hydrocortisone were examined by in vitro functional studies. The expression of this truncated AGT protein was relatively low with a dose-dependent manner. This truncated mutation diminished the interaction between mutant AGT and renin. The truncated AGT also altered the glucocorticoid receptor (GR)-dependent transactivation, indicating that AGT may affect the development of proximal convoluted tubule by alteration of glucocorticoid-dependent transactivation. In hepatocytes, hydrocortisone increased the AGT level by accentuating the stability of mutant AGT and increasing its binding with renin. Therefore, hydrocortisone may exert the therapeutic effect through the enhanced stability and interaction with renin of truncated AGT in patients carrying this AGT mutation.
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Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 330, Taiwan;
| | - Shih-Ming Huang
- Department of Biochemistry, National Defense Medical Center, Taipei 114, Taiwan;
| | - Martin Konrad
- Department of General Pediatrics, University Children’s Hospital Münster, 481 Münster, Germany;
| | - Jing-Long Huang
- Division of Pediatric Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 330, Taiwan;
| | - Steven W. Shaw
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital and Chang Gung University, Taipei 114, Taiwan;
| | - Ya-Chung Tian
- Division of Nephrology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 330, Taiwan;
| | - Ho-Yen Chueh
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 330, Taiwan;
| | - Wen-Lang Fan
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan;
| | - Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA 900, USA;
| | - Jhao-Jhuang Ding
- Department of Pediatrics, Tri-Service General Hospital, Taipei 114, Taiwan;
| | - Ming-Chou Chiang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan 330, Taiwan;
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, Taipei 114, Taiwan
- Correspondence: ; Tel.: +886-2-87927213; Fax: +886-2-87927134
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4
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Viering DHHM, Bech AP, de Baaij JHF, Steenbergen EJ, Danser AHJ, Wetzels JFM, Bindels RJM, Deinum J. Functional tests to guide management in an adult with loss of function of type-1 angiotensin II receptor. Pediatr Nephrol 2021; 36:2731-2737. [PMID: 33768328 PMCID: PMC8370907 DOI: 10.1007/s00467-021-05018-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/04/2021] [Accepted: 02/17/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Genetic loss of function of AGT (angiotensinogen), REN (renin), ACE (angiotensin-converting enzyme), or AGTR1 (type-1 angiotensin II receptor) leads to renal tubular dysgenesis (RTD). This syndrome is almost invariably lethal. Most surviving patients reach stage 5 chronic kidney disease at a young age. METHODS Here, we report a 28-year-old male with a homozygous truncating mutation in AGTR1 (p.Arg216*), who survived the perinatal period with a mildly impaired kidney function. In contrast to classic RTD, kidney biopsy showed proximal tubules that were mostly normal. During the subsequent three decades, we observed evidence of both tubular dysfunction (hyperkalemia, metabolic acidosis, salt-wasting and a urinary concentrating defect) and glomerular dysfunction (reduced glomerular filtration rate, currently ~30 mL/min/1.73 m2, accompanied by proteinuria). To investigate the recurrent and severe hyperkalemia, we performed a patient-tailored functional test and showed that high doses of fludrocortisone induced renal potassium excretion by 155%. Furthermore, fludrocortisone lowered renal sodium excretion by 39%, which would have a mitigating effect on salt-wasting. In addition, urinary pH decreased in response to fludrocortisone. Opposite effects on urinary potassium and pH occurred with administration of amiloride, further supporting the notion that a collecting duct is present and able to react to fludrocortisone. CONCLUSIONS This report provides living proof that even truncating loss-of-function mutations in AGTR1 are compatible with life and relatively good GFR and provides evidence for the prescription of fludrocortisone to treat hyperkalemia and salt-wasting in such patients.
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Affiliation(s)
- Daan H. H. M. Viering
- grid.10417.330000 0004 0444 9382Department of Physiology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Anneke P. Bech
- grid.415930.aDepartment of Nephrology, Rijnstate, Arnhem, the Netherlands
| | - Jeroen H. F. de Baaij
- grid.10417.330000 0004 0444 9382Department of Physiology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Eric J. Steenbergen
- grid.10417.330000 0004 0444 9382Department of Pathology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - A. H. Jan Danser
- grid.5645.2000000040459992XDepartment of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Jack F. M. Wetzels
- grid.10417.330000 0004 0444 9382Department of Nephrology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - René J. M. Bindels
- grid.10417.330000 0004 0444 9382Department of Physiology, Radboud University Medical Centre, Radboud Institute for Molecular Life Sciences, Nijmegen, the Netherlands
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Centre, Huispost 463, Geert Grooteplein 8, 6525, GA, Nijmegen, the Netherlands.
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5
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Rotem-Grunbaum B, Landau D. Genetic renal disease classification by hormonal axes. Pediatr Nephrol 2020; 35:2211-2219. [PMID: 31828468 DOI: 10.1007/s00467-019-04437-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 11/23/2019] [Accepted: 11/26/2019] [Indexed: 12/31/2022]
Abstract
The kidneys, which regulate many homeostatic pathways, are also a major endocrinological target organ. Many genetic renal diseases can be classified according to the affected protein along such endocrinological pathways. In this review, we examine the hypothesis that a more severe phenotype is expected as the affected protein is located more distally along such pathways. Thus, the location of a defect along its endocrinological pathway should be taken into consideration, in addition to the mutation type, when assessing genetic renal disease severity.
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Affiliation(s)
- Bar Rotem-Grunbaum
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Landau
- Department of Pediatrics B, Schneider Children's Medical Center of Israel, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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6
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Tseng MH, Huang SM, Huang JL, Fan WL, Konrad M, Shaw SW, Lien R, Chien HP, Ding JJ, Wu TW, Tsai JD, Tian YC, Lee HJ, Cheng PJ, Hsu JF, Lin SH. Autosomal Recessive Renal Tubular Dysgenesis Caused by a Founder Mutation of Angiotensinogen. Kidney Int Rep 2020; 5:2042-2051. [PMID: 33163725 PMCID: PMC7609895 DOI: 10.1016/j.ekir.2020.08.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/11/2020] [Indexed: 12/30/2022] Open
Abstract
Introduction Autosomal recessive renal tubular dysgenesis (ARRTD) caused by inactivation mutations in AGT, REN, ACE, and AGTR is a very rare but fatal disorder with an unknown prevalence. Methods We report 6 Taiwanese individuals with ARRTD from 6 unrelated families diagnosed by renal histology. Clinical features, outcome, and prevalence of carrier heterozygosity were examined. Results All patients exhibited antenatal oligohydramnios, postnatal anuria, pulmonary hypoplasia, and profound hypotension refractory to interventions. Angiotensinogen (AGT) protein levels were diminished in the liver, along with reduced serum AGT, angiotensin I (Ang I) and angiotensin II (Ang II) levels. Neonatal demise occurred in all but 1 case. All individuals carried the same homozygous E3_E4 del:2870bp deletion+9bp insertion in AGT, which led to a truncated protein (1-292 amino acid). The allelic frequency of this heterozygous AGT mutation was approximately 1.2% (6/500), suggesting that ARRTD may not be exceedingly rare in Taiwan. This mutation results in skipping of exons encoding the serpin domain of AGT, which is important for renin interaction and the generation of truncated protein. In silico modeling revealed a diminished interaction between mutant AGT and renin. One patient survived after responding to high-dose hydrocortisone therapy, with resolution of profound hypotension, accompanied by an increase in serum AGT, Ang I, and Ang II levels. Conclusion This AGT mutation may lead to the diminished interaction with renin and decreased Ang I and Ang II generation. Hydrocortisone may potentially rescue cases of ARRTD caused by this truncated AGT.
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Affiliation(s)
- Min-Hua Tseng
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Ming Huang
- Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Jing-Long Huang
- Division of Pediatric Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Wen-Lang Fan
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Martin Konrad
- Department of General Pediatrics, University Children’s Hospital Münster, Münster, Germany
| | - Steven W. Shaw
- Department of Obstetrics and Gynecology, Taipei Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Reyin Lien
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Hui-Ping Chien
- Department of Pathology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Jhao-Jhuang Ding
- Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tai-Wei Wu
- Fetal and Neonatal Institute, Division of Neonatology Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Jeng-Daw Tsai
- Division of Nephrology, Department of Pediatrics, MacKay Children's Hospital, Taipei, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Ya-Chung Tian
- Division of Nephrology, Department of Medicine, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Hwei-Jen Lee
- Department of Biochemistry, National Defense Medical Center, Taipei, Taiwan
| | - Po-Jen Cheng
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Jen-Fu Hsu
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, Taipei, National Defense Medical Center, Taiwan
- Correspondence: Shih-Hua Lin, Division of Nephrology, Department of Medicine, Tri-Service General Hospital, No 325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan.
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7
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Bi-allelic mutations in renin-angiotensin system genes, associated with renal tubular dysgenesis, can also present as a progressive chronic kidney disease. Pediatr Nephrol 2020; 35:1125-1128. [PMID: 32198635 DOI: 10.1007/s00467-020-04524-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/19/2020] [Accepted: 02/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Bi-allelic loss of function variations in genes encoding proteins of the renin-angiotensin system (AGT, ACE, REN, AGTR1) are associated with autosomal recessive renal tubular dysgenesis, a severe disease characterized by the absence of differentiated proximal tubules leading to fetal anuria and neonatal end-stage renal disease. CASE-DIAGNOSIS/TREATMENT We identified bi-allelic loss of function mutations in ACE, the gene encoding angiotensin-converting enzyme, in 3 unrelated cases displaying progressive chronic renal failure, whose DNAs had been sent for suspicion of juvenile hyperuricemic nephropathy, nephronophthisis, and cystic renal disease, respectively. In all cases, patients were affected with anemia whose severity was unexpected regarding the level of renal failure and with important polyuro-polydipsia. CONCLUSIONS Bi-allelic loss of function mutation of ACE can have atypical and sometimes late presentation with chronic renal failure, anemia (out of proportion with the level of renal failure), and polyuro-polydipsia. These data illustrate the usefulness of next generation sequencing and "agnostic" approaches to elucidate cases with chronic kidney disease of unknown etiology and to broaden the spectrum of phenotypes of monogenic renal diseases. It also raises the question of genetic modifiers involved in the variation of the phenotypes associated with these mutations.
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8
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Singer P, Sethna CB, Castellanos-Reyes L, Yaskiv O, Bijol V. Kidney Biopsy Findings in a Patient With Valproic Acid-Associated Fanconi Syndrome. Pediatr Dev Pathol 2019; 22:370-374. [PMID: 30565480 DOI: 10.1177/1093526618819334] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 7-year-old boy with a history of febrile illness-related epilepsy syndrome presented with proteinuria and elevated creatinine. His severe epileptic disorder has been treated since age 2 with multiple antiepileptic medications, including valproic acid. More recently, he was noted to have features of Fanconi syndrome with acidosis, hypophosphatemia, hypokalemia, glucosuria, and nephrotic-range proteinuria. This was managed with supplements; however, in the setting of rising creatinine and prominent proteinuria, a kidney biopsy was performed. Renal cortex revealed markedly decreased expression of proximal tubule markers and increased expression of markers of distal nephron differentiation. Such findings have been described in several genetic and acquired conditions, including renal tubular dysgenesis, severe hypoxic injury following renal artery stenosis, and toxic injury related to in utero exposure to angiotensin-converting-enzyme inhibitors. Such changes have not been reported before in valproic acid-associated Fanconi syndrome, although in general, morphologic findings in this condition have not been well established in the literature.
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Affiliation(s)
- Pamela Singer
- 1 Pediatric Nephrology, Cohen Children's Medical Center of New York, Zucker School of Medicine, Hofstra University, Hempstead, New York
| | - Christine B Sethna
- 1 Pediatric Nephrology, Cohen Children's Medical Center of New York, Zucker School of Medicine, Hofstra University, Hempstead, New York
| | - Laura Castellanos-Reyes
- 1 Pediatric Nephrology, Cohen Children's Medical Center of New York, Zucker School of Medicine, Hofstra University, Hempstead, New York
| | - Oksana Yaskiv
- 2 Department of Pathology, Zucker School of Medicine, Hofstra University, Hempstead, New York
| | - Vanesa Bijol
- 2 Department of Pathology, Zucker School of Medicine, Hofstra University, Hempstead, New York
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9
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Das Bhowmik A, Dalal A, Tandon A, Aggarwal S. Exome sequencing identifies novel ACE splice-site variant in a fetus with renal tubular dysgenesis. J Obstet Gynaecol Res 2018; 44:2181-2185. [PMID: 30058238 DOI: 10.1111/jog.13771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 07/04/2018] [Indexed: 11/29/2022]
Abstract
We report a 32-week fetus conceived of consanguineous parentage which presented with severe early onset oligohydramnios and history of a similarly affected sibling in previous pregnancy. Ultrasonography and autopsy were inconclusive, prompting exome sequencing on fetal DNA. This resulted in identification of a homozygous novel 3' splice-site variation in intron 17 of the ACE gene (NM_000789.3:c.2642-1G>A), confirming diagnosis of autosomal recessive renal tubular dysgenesis, and facilitating prenatal diagnosis in subsequent pregnancy.
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Affiliation(s)
- Aneek Das Bhowmik
- Diagnostics Division, Centre for DNA Fingerprinting and Diagnostics, Hyderabad, India
| | - Ashwin Dalal
- Diagnostics Division, Centre for DNA Fingerprinting and Diagnostics, Hyderabad, India
| | - Ashwani Tandon
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Shagun Aggarwal
- Diagnostics Division, Centre for DNA Fingerprinting and Diagnostics, Hyderabad, India.,Department of Medical Genetics, Nizam's Institute of Medical Sciences, Hyderabad, India
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10
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Richer J, Daoud H, Geier P, Jarinova O, Carson N, Feberova J, Ben Fadel N, Unrau J, Bareke E, Khatchadourian K, Bulman DE, Majewski J, Boycott KM, Dyment DA. Resolution of refractory hypotension and anuria in a premature newborn with loss-of-function of ACE. Am J Med Genet A 2015; 167:1654-8. [PMID: 25899979 DOI: 10.1002/ajmg.a.37067] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 03/05/2015] [Indexed: 11/07/2022]
Abstract
We present the investigation and management of a premature, hypotensive neonate born after a pregnancy complicated by anhydramnios to highlight the impact of early and informed management for rare kidney disease. Vasopressin was used to successfully treat refractory hypotension and anuria in the neonate born at 27 weeks of gestation. Next generation sequencing of a targeted panel of genes was then performed in the neonate and parents. Subsequently, two compound heterozygous deletions leading to frameshift mutations were identified in the angiotensin 1-converting enzyme gene ACE; exon 5:c.820_821delAG (p.Arg274Glyfs*117) and exon24: c.3521delG (p.Gly1174Alafs*12), consistent with a diagnosis of renal tubular dysgenesis. In light of the molecular diagnosis, identification, and treatment of associated low aldosterone level resulted in further improvement in renal function and only mild residual chronic renal failure is present at 14 months of age. Truncating alterations in ACE most often result in fetal demise during gestation or in the first days of life and typically as a result of the Potter sequence. The premature delivery, and serendipitous early treatment with vasopressin, and then later fludrocortisone, resulted in an optimal outcome in an otherwise lethal condition.
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Affiliation(s)
- Julie Richer
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Hussein Daoud
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Pavel Geier
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Olga Jarinova
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nancy Carson
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jana Feberova
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Jennifer Unrau
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Eric Bareke
- McGill University and Genome Quebec Innovation Centre, Montréal, Québec, Canada
| | - Karine Khatchadourian
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Dennis E Bulman
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Jacek Majewski
- McGill University and Genome Quebec Innovation Centre, Montréal, Québec, Canada
| | - Kym M Boycott
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - David A Dyment
- Department of Genetics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Ontario, Canada
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Hibino S, Sasaki H, Abe Y, Hojo A, Uematsu M, Sekine T, Itabashi K. Renal function in angiotensinogen gene-mutated renal tubular dysgenesis with glomerular cysts. Pediatr Nephrol 2015; 30:357-60. [PMID: 25414114 DOI: 10.1007/s00467-014-3007-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 10/28/2014] [Accepted: 11/05/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Inherited renal tubular dysgenesis (RTD) is caused by mutations in the genes encoding the components of the renin-angiotensin system (RAS). RTD is characterized by oligohydramnios, renal failure, neonatal hypocalvaria, and severe hypotension. The histological characteristics, underlying mechanism, and long-term prognosis remain poorly known. CASE-DIAGNOSIS/TREATMENT We describe here a 4-year-old female with RTD. Endocrinologic analysis showed a discrepancy between low plasma renin activity and high active renin concentration, suggesting a loss of the renin substrate, angiotensinogen (AGT). Direct sequencing revealed a frameshift deletion at nucleotide 1,355 in exon 5 in the AGT gene. Although a histological hallmark is regarded to be the absence or poor development of the proximal tubule, the patient does have minimally impaired function of the proximal tubule. Glomerular cysts without glomerular tufts were noted in approximately half of the glomeruli. The urinary concentrating ability and sodium reabsorption and potassium excretion in the distal nephron were severely affected. CONCLUSIONS The patient has an impaired function of the distal nephron despite minimally affected function of the proximal tubule, probably attributed to renal tubular dysgenesis and fetal hypoperfusion. The renal tubular maturity and the severity of ischemic injury may be key determinants of the clinical symptoms and pathological findings in RTD, in which the RAS plays an important role.
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Affiliation(s)
- Satoshi Hibino
- Department of Pediatrics, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo, 142-8666, Japan,
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Abstract
Renal tubular dysgenesis (RTD) is a severe foetal disorder characterised by the absence or poor development of proximal tubules, early onset and persistent anuria (leading to oligohydramnios and the Potter sequence) and ossification defects of the skull. In most cases, early death occurs from pulmonary hypoplasia, anuria and refractory arterial hypotension. RTD may be acquired during foetal development or inherited as an autosomal recessive disease. Inherited RTD is genetically heterogeneous and linked to mutations in the genes encoding the major components of the renin-angiotensin system (RAS): angiotensinogen, renin, angiotensin-converting enzyme or angiotensin II receptor type 1. Mutations result in either the absence of production or lack of efficacy of angiotensin II. Secondary RTD has been observed in various situations, particularly in the donor twin of severe twin-to-twin transfusion syndrome, in foetuses affected with congenital haemochromatosis or in foetuses exposed to RAS blockers. All cases result in renal hypoperfusion. These examples illustrate the importance of a functional RAS in the maintenance of blood pressure and renal blood flow for humans during foetal life. The diagnosis of RTD in an anuric foetus with normal renal sonography results is important for the management of the foetus or neonate. Depending on the genetic or secondary cause of the disease, such findings can lead to genetic counselling or the prevention of recurrence in subsequent pregnancies.
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13
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The molecular basis of blood pressure variation. Pediatr Nephrol 2013; 28:387-99. [PMID: 22763847 DOI: 10.1007/s00467-012-2206-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 04/19/2012] [Accepted: 04/24/2012] [Indexed: 12/15/2022]
Abstract
Advances in genetic mapping and sequencing techniques have led to substantial progress in the study of rare monogenic (Mendelian) forms of abnormal blood pressure. Many disease-defining pathways for hypertension have been identified in the past two decades. Perturbations in renal salt handling appear to be a common mechanism underlying these rare syndromes of hypertension. Excess activation at various points in the mineralocorticoid signaling pathway and malfunctioning of the autonomic (specifically sympathetic) nervous system have both been implicated in inducing hypertension, while complementary studies examining low blood pressure phenotypes have identified novel pathways exclusively linked to renal salt wasting in either the thick ascending limb or the distal nephron. The genetic defects and the physiological and cellular pathways affected in these various disorders are reviewed here. Importantly, studies have suggested that genetic variation affecting these same genes and pathways may play an important role in explaining the variation of blood pressure levels in the general population. The investigation of rare syndromes of human blood pressure variation has important implications for improving the diagnosis and treatment of hypertension.
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Nogueira AB, Schultz R, Liao AW, Fancisco RPV, Zugaib M. Renal tubular dysgenesis with hypocalvaria and ileocecal valve agenesis: an autopsy report. AUTOPSY AND CASE REPORTS 2012; 2:27-33. [PMID: 31528585 PMCID: PMC6735574 DOI: 10.4322/acr.2012.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 08/02/2012] [Indexed: 11/23/2022] Open
Abstract
Renal tubular dysgenesis (RTD) is a rare, lethal, autosomal recessive disorder characterized by non-differentiation of the renal proximal convoluted tubules, resulting in oligohydramnios. It is usually diagnosed in the second trimester of pregnancy, following the oligohydramnios sequence, pulmonary hypoplasia and hypocalvaria. The prognosis is poor, and death usually occurs in utero or within the first few days of life. The pathogenesis of RTD is associated with the perinatal use of drugs, such as angiotensin- converting enzyme inhibitors, angiotensin II receptor antagonists, and anti- inflammatory drugs, as well as with fetal transfusion syndrome, genetic mutations in the pathway of the renin-angiotensin system pathway, cocaine snorting, or other pathological mechanisms that reduce renal blood flow. Here, we report the autopsy of a neonate born to consanguineous parents at 38 weeks of gestation, with RTD, decreased amniotic fluid, oligohydramnios sequence, hypocalvaria, pulmonary hypoplasia, and ileocecal valve agenesis. To our knowledge, the latter has never been reported associated with RTD.
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Affiliation(s)
- Ariel Barreto Nogueira
- Department of Pathology - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Regina Schultz
- Department of Pathology - Hospital das Clínicas - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | - Adolfo Wenjaw Liao
- Department of Obstetrics and Gynecology - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
| | | | - Marcelo Zugaib
- Department of Obstetrics and Gynecology - Faculdade de Medicina - Universidade de São Paulo, São Paulo/SP - Brazil
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Kim SY, Kang HG, Kim EK, Choi JH, Choi Y, Cheong HI. Survival over 2 years of autosomal-recessive renal tubular dysgenesis. Clin Kidney J 2012; 5:56-8. [PMID: 26069751 PMCID: PMC4400456 DOI: 10.1093/ndtplus/sfr153] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Accepted: 09/23/2011] [Indexed: 12/03/2022] Open
Abstract
Autosomal-recessive renal tubular dysgenesis (AR-RTD) is a rare disorder caused by a genetic defect in the renin–angiotensin system. Although AR-RTD has typically been known as a lethal disease due to refractory hypotension and renal failure immediately after birth, few cases have reported survival of the neonatal period. We report here an additional case of AR-RTD, who had novel ACE mutations and survived over 2 years and provide a review of the five previously reported surviving cases. In conclusion, AR-RTD is not a uniformly fatal disease, although factors affecting the survival remain unknown.
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Affiliation(s)
- Su Yeong Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea ; Research Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea
| | - Ee Kyung Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jung Hwan Choi
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Yong Choi
- Department of Pediatrics, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea ; Research Center for Rare Diseases, Seoul National University Hospital, Seoul, Korea ; Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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Gribouval O, Morinière V, Pawtowski A, Arrondel C, Sallinen SL, Saloranta C, Clericuzio C, Viot G, Tantau J, Blesson S, Cloarec S, Machet MC, Chitayat D, Thauvin C, Laurent N, Sampson JR, Bernstein JA, Clemenson A, Prieur F, Daniel L, Levy-Mozziconacci A, Lachlan K, Alessandri JL, Cartault F, Rivière JP, Picard N, Baumann C, Delezoide AL, Belar Ortega M, Chassaing N, Labrune P, Yu S, Firth H, Wellesley D, Bitzan M, Alfares A, Braverman N, Krogh L, Tolmie J, Gaspar H, Doray B, Majore S, Bonneau D, Triau S, Loirat C, David A, Bartholdi D, Peleg A, Brackman D, Stone R, DeBerardinis R, Corvol P, Michaud A, Antignac C, Gubler MC. Spectrum of mutations in the renin-angiotensin system genes in autosomal recessive renal tubular dysgenesis. Hum Mutat 2011; 33:316-26. [PMID: 22095942 DOI: 10.1002/humu.21661] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Accepted: 11/08/2011] [Indexed: 11/11/2022]
Abstract
Autosomal recessive renal tubular dysgenesis (RTD) is a severe disorder of renal tubular development characterized by early onset and persistent fetal anuria leading to oligohydramnios and the Potter sequence, associated with skull ossification defects. Early death occurs in most cases from anuria, pulmonary hypoplasia, and refractory arterial hypotension. The disease is linked to mutations in the genes encoding several components of the renin-angiotensin system (RAS): AGT (angiotensinogen), REN (renin), ACE (angiotensin-converting enzyme), and AGTR1 (angiotensin II receptor type 1). Here, we review the series of 54 distinct mutations identified in 48 unrelated families. Most of them are novel and ACE mutations are the most frequent, observed in two-thirds of families (64.6%). The severity of the clinical course was similar whatever the mutated gene, which underlines the importance of a functional RAS in the maintenance of blood pressure and renal blood flow during the life of a human fetus. Renal hypoperfusion, whether genetic or secondary to a variety of diseases, precludes the normal development/ differentiation of proximal tubules. The identification of the disease on the basis of precise clinical and histological analyses and the characterization of the genetic defects allow genetic counseling and early prenatal diagnosis.
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Affiliation(s)
- Olivier Gribouval
- Inserm U983, Faculté de Médecine Paris Descartes, Université Paris Descartes, Paris, France.
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John U, Benz K, Hübler A, Patzer L, Zenker M, Amann K. Oligohydramnios associated with sonographically normal kidneys. Urology 2011; 79:1155-7. [PMID: 22088568 DOI: 10.1016/j.urology.2011.08.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 08/28/2011] [Accepted: 08/30/2011] [Indexed: 11/25/2022]
Abstract
We report a male newborn presenting with sonographically normal kidneys, oligohydramnios during late pregnancy, and persisting anuric renal failure. Despite intensive treatment, the patient suffered from severe hypotension and died at the age of 4 weeks. At autopsy, kidneys were found to be normal; on histology, deranged renal structures, in particular proximal tubuli and vessels, were noted, leading to the diagnosis of renal tubular dysgenesis (RTD). The diagnosis was confirmed by 2 heterozygous nonsense mutations of the ACE gene. Because the recurrence rate of RTD is 25% for the autosomal recessive trait, knowledge and genetic diagnosis of the disease is important for the parents.
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Affiliation(s)
- Ulrike John
- Department of Pediatrics, University of Jena, Germany
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