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Demir BK, Kanık A, Köse M, Hişmi BÖ, Baran M. A surprising cause of proteinuria: Answers. Pediatr Nephrol 2022; 37:1033-1039. [PMID: 34999986 DOI: 10.1007/s00467-021-05363-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Belde Kasap Demir
- Department of Pediatrics, Division of Nephrology and Rheumatology, İzmir Katip Çelebi University, İzmir, Turkey. .,Department of Pediatrics, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey.
| | - Ali Kanık
- Department of Pediatrics, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey.,Department of Pediatrics, İzmir Katip Çelebi University, İzmir, Turkey
| | - Melis Köse
- Department of Pediatrics, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey.,Department of Pediatric Metabolism, İzmir Katip Çelebi University, İzmir, Turkey
| | - Burcu Öztürk Hişmi
- Department of Pediatric Metabolism, Marmara University, İstanbul, Turkey
| | - Maşallah Baran
- Department of Pediatrics, Health Sciences University, Tepecik Training and Research Hospital, İzmir, Turkey.,Department of Pediatrics, Division of Pediatric Gastroenterology, İzmir Katip Çelebi University, İzmir, Turkey
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Contreras JL, Ladino MA, Aránguiz K, Mendez GP, Coban-Akdemir Z, Yuan B, Gibbs RA, Burrage LC, Lupski JR, Chinn IK, Vogel TP, Orange JS, Poli MC. Immune Dysregulation Mimicking Systemic Lupus Erythematosus in a Patient With Lysinuric Protein Intolerance: Case Report and Review of the Literature. Front Pediatr 2021; 9:673957. [PMID: 34095032 PMCID: PMC8172984 DOI: 10.3389/fped.2021.673957] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/14/2021] [Indexed: 12/14/2022] Open
Abstract
Lysinuric protein intolerance (LPI) is an inborn error of metabolism caused by defective transport of cationic amino acids in epithelial cells of intestines, kidneys and other tissues as well as non-epithelial cells including macrophages. LPI is caused by biallelic, pathogenic variants in SLC7A7. The clinical phenotype of LPI includes failure to thrive and multi-system disease including hematologic, neurologic, pulmonary and renal manifestations. Individual presentations are extremely variable, often leading to misdiagnosis or delayed diagnosis. Here we describe a patient that clinically presented with immune dysregulation in the setting of early-onset systemic lupus erythematosus (SLE), including renal involvement, in whom an LPI diagnosis was suspected post-mortem based on exome sequencing analysis. A review of the literature was performed to provide an overview of the clinical spectrum and immune mechanisms involved in this disease. The precise mechanism by which ineffective amino acid transport triggers systemic inflammatory features is not yet understood. However, LPI should be considered in the differential diagnosis of early-onset SLE, particularly in the absence of response to immunosuppressive therapy.
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Affiliation(s)
| | - Mabel A. Ladino
- Universidad de Chile, Reumatóloga Pediátrica Hospital San Juan de Dios, Santiago, Chile
| | - Katherine Aránguiz
- Unidad de Inmunología y Reumatología Hospital Luis Calvo Mackenna, Providencia, Chile
| | - Gonzalo P. Mendez
- Patológo Renal, Departamento de Anatomía Patológica, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Zeynep Coban-Akdemir
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Bo Yuan
- Department of Laboratories, Seattle Children's Hospital, Seattle, WA, United States
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
| | - Richard A. Gibbs
- Sequencing Center, Baylor College of Medicine, Houston, TX, United States
| | - Lindsay C. Burrage
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
- Texas Children's Hospital, Houston, TX, United States
| | - James R. Lupski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, United States
- Sequencing Center, Baylor College of Medicine, Houston, TX, United States
- Texas Children's Hospital, Houston, TX, United States
| | - Ivan K. Chinn
- Texas Children's Hospital, Houston, TX, United States
- Department of Pediatrics, Division of Allergy, Immunology and Retrovirology, Baylor College of Medicine, Houston, TX, United States
| | - Tiphanie P. Vogel
- Texas Children's Hospital, Houston, TX, United States
- Department of Pediatrics, Division of Rheumatology, Baylor College of Medicine, Houston, TX, United States
| | - Jordan S. Orange
- Department of Pediatrics, Vagelos College of Physicians and Surgeons, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University, New York, NY, United States
| | - M. Cecilia Poli
- Facultad de Medicina Universidad del Desarrollo-Clínica Alemana, Santiago, Chile
- Department of Pediatrics, Division of Allergy, Immunology and Retrovirology, Baylor College of Medicine, Houston, TX, United States
- Unidad de Inmunología y Reumatología, Hospital Roberto del Río, Santiago, Chile
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Nicolas C, Bednarek N, Vuiblet V, Boyer O, Brassier A, De Lonlay P, Galmiche L, Krug P, Baudouin V, Pichard S, Schiff M, Pietrement C. Renal Involvement in a French Paediatric Cohort of Patients with Lysinuric Protein Intolerance. JIMD Rep 2015; 29:11-17. [PMID: 26608393 PMCID: PMC5059217 DOI: 10.1007/8904_2015_509] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 02/07/2023] Open
Abstract
Lysinuric protein intolerance (LPI) is a rare autosomal recessive metabolic disorder, caused by defective transport of cationic amino acids at the basolateral membrane of epithelial cells, typically in intestines and kidneys. The SLC7A7 gene, mutated in LPI patients, encodes the light subunit (y+LAT1) of a member of the heterodimeric amino acid transporter family.The diagnosis of LPI is difficult due to unspecific clinical features: protein intolerance, failure to thrive and vomiting after weaning. Later on, patients may present delayed growth osteoporosis, hepatosplenomegaly, muscle hypotonia and life-threatening complications such as alveolar proteinosis, haemophagocytic lymphohistiocytosis and macrophage activation syndrome. Renal involvement is also a serious complication with tubular and more rarely, glomerular lesions that may lead to end-stage kidney disease (ESKD). We report six cases of LPI followed in three different French paediatric centres who presented LPI-related nephropathy during childhood. Four of them developed chronic kidney disease during follow-up, including one with ESKD. Five developed chronic tubulopathies and one a chronic glomerulonephritis. A histological pattern of membranoproliferative glomerulonephritis was first associated with a polyclonal immunoglobulin deposition, treated by immunosuppressive therapy. He then required a second kidney biopsy after a relapse of the nephrotic syndrome; the immunoglobulin deposition was then monoclonal (IgG1 kappa). This is the first observation of an evolution from a polyclonal to a monotypic immune glomerulonephritis. Immune dysfunction potentially attributable to nitric oxide overproduction secondary to arginine intracellular trapping is a debated complication in LPI. Our results suggest all LPI patients should be monitored for renal disease regularly.
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Affiliation(s)
- C Nicolas
- Department of Paediatrics, Nephrology Paediatric Unit, CHU Reims, France.
| | - N Bednarek
- Department of Neonatalogy, Metabolic Unit, CHU Reims, France
| | - V Vuiblet
- Departments of Nephrology and Pathology, CHU de Reims, France
| | - O Boyer
- Department of Paediatric Nephrology, APHP Necker Enfants-Malades Hospital, INSERM U1163, Imagine Institute, Paris Descartes University, Sorbonne Paris Cité University, Paris, France
| | - A Brassier
- Department of Metabolic Diseases, APHP Necker Enfants-Malades Hospital, Paris, France
| | - P De Lonlay
- Department of Metabolic Diseases, APHP Necker Enfants-Malades Hospital, Paris, France
| | - L Galmiche
- Department of Pathology, APHP Necker Enfants-Malades Hospital, Paris, France
| | - P Krug
- Department of Paediatric Nephrology, APHP Necker Enfants-Malades Hospital, INSERM U1163, Imagine Institute, Paris Descartes University, Sorbonne Paris Cité University, Paris, France
| | - V Baudouin
- Department of Paediatric Nephrology, APHP Robert Debré Hospital, Paris, France
| | - S Pichard
- Reference Center of Inborn Errors of Metabolism, APHP Robert Debré Hospital, INSERM U1141, Paris-Diderot University, Sorbonne Paris Cité University, Paris, France
| | - M Schiff
- Reference Center of Inborn Errors of Metabolism, APHP Robert Debré Hospital, INSERM U1141, Paris-Diderot University, Sorbonne Paris Cité University, Paris, France
| | - C Pietrement
- Department of Paediatrics, Nephrology Paediatric Unit, CHU Reims, France
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Ogier de Baulny H, Schiff M, Dionisi-Vici C. Lysinuric protein intolerance (LPI): a multi organ disease by far more complex than a classic urea cycle disorder. Mol Genet Metab 2012; 106:12-7. [PMID: 22402328 DOI: 10.1016/j.ymgme.2012.02.010] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 02/08/2012] [Accepted: 02/09/2012] [Indexed: 12/26/2022]
Abstract
Lysinuric protein intolerance (LPI) is an inherited defect of cationic amino acid (lysine, arginine and ornithine) transport at the basolateral membrane of intestinal and renal tubular cells caused by mutations in SLC7A7 encoding the y(+)LAT1 protein. LPI has long been considered a relatively benign urea cycle disease, when appropriately treated with low-protein diet and l-citrulline supplementation. However, the severe clinical course of this disorder suggests that LPI should be regarded as a severe multisystem disease with uncertain outcome. Specifically, immune dysfunction potentially attributable to nitric oxide (NO) overproduction secondary to arginine intracellular trapping (due to defective efflux from the cell) might be a crucial pathophysiological route explaining many of LPI complications. The latter comprise severe lung disease with pulmonary alveolar proteinosis, renal disease, hemophagocytic lymphohistiocytosis with subsequent activation of macrophages, various auto-immune disorders and an incompletely characterized immune deficiency. These results have several therapeutic implications, among which lowering the l-citrulline dosage may be crucial, as excessive citrulline may worsen intracellular arginine accumulation.
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Affiliation(s)
- Hélène Ogier de Baulny
- APHP, Reference Center for Inherited Metabolic Disease, Hôpital Robert Debré, F-75019 Paris, France
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Barilli A, Rotoli BM, Visigalli R, Bussolati O, Gazzola GC, Gatti R, Dionisi-Vici C, Martinelli D, Goffredo BM, Font-Llitjós M, Mariani F, Luisetti M, Dall'Asta V. Impaired phagocytosis in macrophages from patients affected by lysinuric protein intolerance. Mol Genet Metab 2012; 105:585-9. [PMID: 22325938 DOI: 10.1016/j.ymgme.2012.01.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 01/10/2012] [Accepted: 01/10/2012] [Indexed: 11/16/2022]
Abstract
Lysinuric Protein Intolerance (LPI, MIM 222700) is a recessive aminoaciduria caused by defective cationic amino acid transport in epithelial cells of intestine and kidney. SLC7A7, the gene mutated in LPI, codifies for the y+LAT1 subunit of system y(+)L amino acid transporter. LPI patients frequently display severe complications, such as pulmonary disease, haematological abnormalities and disorders of the immune response. The transport defect may explain only a part of the clinical aspects of the disease, while the mechanisms linking the genetic defect to the clinical features of the patients remain thus far obscure. The aim of the study is to investigate the consequences of SLC7A7 mutations on specific macrophage functions, so as to evaluate if a macrophage dysfunction may have a role in the development of pulmonary and immunological complications of LPI. The results presented 1) confirm previous data obtained in one LPI patient, demonstrating that arginine influx through system y(+)L is markedly compromised in LPI macrophages; 2) demonstrate that also system y(+)L-mediated arginine efflux is significantly lower in LPI macrophages than in normal cells and 3) demonstrate that the phagocytic activity of LPI macrophages is severely impaired. In conclusion, SLC7A7/y+LAT1 mutations lead to a defective phenotype of macrophages, supporting the pathogenetic role of these cells in the development of LPI-associated complications.
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Affiliation(s)
- Amelia Barilli
- Dipartimento di Medicina Sperimentale, Sezione di Patologia Generale e Clinica, Università degli Studi di Parma, Parma, Italy
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Ming JE, Stiehm ER. Genetic syndromic immunodeficiencies with antibody defects. Immunol Allergy Clin North Am 2009; 28:715-36, vii. [PMID: 18940571 DOI: 10.1016/j.iac.2008.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This article reviews the major syndromic immunodeficiencies with significant antibody defects, many of which may require intravenous immunogammaglobulin therapy. The authors define syndromic immunodeficiency as an illness associated with a characteristic group of phenotypic abnormalities or laboratory features that comprise a recognizable syndrome. Many are familial with a defined inheritance pattern. Immunodeficiency may not be a major part of the illness and may not be present in all patients; thus, these conditions differ from primary immunodeficiency syndromes, in which immune abnormalities are a consistent and prominent feature of their disease.
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Affiliation(s)
- Jeffrey E Ming
- Division of Human Genetics, Department of Pediatrics, The Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, 3615 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Maruyama K, Suzuki T, Koizumi T, Sugie H, Fukuda T, Ito M, Hirato J. Congenital form of glycogen storage disease type IV: a case report and a review of the literature. Pediatr Int 2004; 46:474-7. [PMID: 15310318 DOI: 10.1111/j.1442-200x.2004.01916.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Keinchi Maruyama
- Department of Pediatric Neurology, Hamamatsu City Medical Center for Developmental Medicine, Hamamatsu, Japan.
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Ming JE, Stiehm ER, Graham JM. Syndromic immunodeficiencies: genetic syndromes associated with immune abnormalities. Crit Rev Clin Lab Sci 2004; 40:587-642. [PMID: 14708957 DOI: 10.1080/714037692] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
In syndromic immunodeficiencies, clinical features not directly associated with the immune defect are prominent. Patients may present with either infectious complications or extra-immune medical issues. In addition to the immunologic abnormality, a wide range of organ systems may be affected. Patients may present with disturbances in skeletal, neurologic, dermatologic, or gastrointestinal function or development. These conditions can be caused by developmental abnormalities, chromosomal aberrations, metabolic disorders, or teratogens. For a number of these conditions, recent advances have resulted in an enhanced understanding of their genetic basis. The finding of immune deficits in a number of defined syndromes with congenital anomalies suggests that an underlying genetic syndrome should be considered in those patients in whom a significant non-immune feature is present.
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Affiliation(s)
- Jeffrey E Ming
- Department of Pediatrics, Division of Human Genetics and Molecular Biology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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