Reproductive Issues for Adults With Autosomal Dominant Polycystic Kidney Disease

Overview of ADPKD in Pregnancy

Autosomal dominant polycystic kidney disease (ADPKD) is a systemic disorder that often affects patients in their third to fifth decades of life and is characterized by kidney cysts, chronic kidney disease (CKD), hypertension, and hepatic cysts. The development of clinical symptoms often coincides with childbearing years. Consequently, there are several considerations regarding pregnant patients with ADPKD. In this review, we detail the effects and management of ADPKD in the peripartum period and discuss family planning options, including assisted reproductive techniques (ART) and preimplantation genetic testing.

Genetic syndromes leading to male infertility: a systematic review

Male-factor infertility is a multifactorial, complex, and increasingly common condition, of which genetic factors have more frequently been implicated. Not only are the causal relationships between genetic variation and male infertility phenotypes understudied, but also the differences in frequency of disease-causing genetic alterations within different geographic and ethnic groups. Guidelines remain inconsistent as to recommended genomic testing during the male infertility workup. Our current fund of knowledge limits our diagnostic capability where the etiology of male infertility remains idiopathic in about 40% of patients, despite advances in genomic sequencing and testing.

Clinical outcomes following preimplantation genetic testing for monogenic conditions: a systematic review of observational studies

OBJECTIVE

We aimed to report a summary of clinical outcomes following preimplantation genetic testing for monogenic conditions, by performing a systematic review of published literature on clinical pregnancy and live birth rates following preimplantation genetic testing due to a monogenic indication. Additionally, we aimed to undertake a subgroup analysis of clinical outcomes of concurrent monogenic and aneuploidy screening.

DATA SOURCES

Three electronic databases (MEDLINE, EMBASE, and PubMed) were searched from inception to May 2024.

STUDY ELIGIBILITY CRITERIA

Quantitative data audits, observational studies, and case series reporting clinical outcomes for individuals undergoing preimplantation genetic testing for a monogenic indication were included. Only studies using blastocyst biopsies with polymerase chain reaction-based or genome-wide haplotyping methods for molecular analysis were eligible to reflect current laboratory practice.

METHODS

Quality assessment was performed following data extraction using an adaptation of the Joanna Briggs critical appraisal tool for case series. Results were extracted, and pooled mean clinical pregnancy rates and birth rates were calculated with 95% confidence intervals (95% CI). We compared outcomes between those with and without concurrent preimplantation genetic testing for aneuploidy.

RESULTS

Our search identified 1372 publications; 51 were eligible for inclusion. Pooled data on 5305 cycles and 5229 embryo transfers yielded 1806 clinical pregnancies and 1577 births. This translated to clinical pregnancy and birth rates of 34.0% [95% CI: 32.8%-35.3%] and 29.7% [95% CI: 28.5%-31.0%] per cycle and 24.8% [95% CI: 23.6%-26.0%] and 21.7% [95% CI: 20.8%-23.1%] per embryo transfer. In studies with concurrent aneuploidy screening, clinical pregnancy and birth rates were 43.3% [95% CI: 40.2%-46.5%] and 37.6% [95% CI: 34.6%-40.8%] per cycle and 37.0% [95% CI: 33.9%-40.3%] and 31.8% [95% CI: 28.8%-35.0%] per embryo transfer. Studies without aneuploidy screening reported clinical pregnancy and birth rates of 32.5% [95% CI: 31.0%-34.1%] and 28.1% [95% CI: 26.6%-29.7%] per cycle and 21.2% [95% CI: 19.8%-22.6%] and 18.6% [95% CI: 17.3%-20.0%] per embryo transfer.

CONCLUSION

This systematic review reveals promising clinical outcome figures for this indication group. Additionally, synthesizing the published scientific literature on clinical outcomes from preimplantation genetic testing for monogenic conditions provides a rigorous, noncommercial evidence base for counseling.

Secondary infertility due to necrospermia in men with autosomal-dominant polycystic kidney disease: a report of two cases

Autosomal-dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disease characterized by the formation of numerous cysts in organs other than the kidneys. Although female patients with ADPKD do not have direct fertility problems, infertility in male patients may arise following the formation of cystic lesions in the lower seminal tract, which impair the function of spermatozoa. Generally, the treatment strategy for necrospermia depends on the severity of sperm viability, and intracytoplasmic sperm injection may be offered to patients with necrospermia. We report two cases of secondary infertility in men with ADPKD. These men experienced an inability to reproduce naturally after the previous birth of a child, suggesting a progressive deterioration of semen quality. Semen analysis showed necrospermia in both patients, and transrectal ultrasound revealed marked dilatation of the seminal vesicles bilaterally. The main cause of secondary infertility in male patients with ADPKD is sperm death resulting from progressive dilatation of seminal vesicles. Further research is needed on the appropriate follow-up schedule for men with ADPKD who desire to reproduce naturally.

The screening, diagnosis, and management of patients with autosomal dominant polycystic kidney disease: A national consensus statement from Taiwan

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited cause of end-stage kidney disease (ESKD) worldwide. Guidelines for the diagnosis and management of ADPKD in Taiwan remains unavailable. In this consensus statement, we summarize updated information on clinical features of international and domestic patients with ADPKD, followed by suggestions for optimal diagnosis and care in Taiwan. Specifically, counselling for at-risk minors and reproductive issues can be important, including ethical dilemmas surrounding prenatal diagnosis and pre-implantation genetic diagnosis. Studies reveal that ADPKD typically remains asymptomatic until the fourth decade of life, with symptoms resulting from cystic expansion with visceral compression, or rupture. The diagnosis can be made based on a detailed family history, followed by imaging studies (ultrasound, computed tomography, or magnetic resonance imaging). Genetic testing is reserved for atypical cases mostly. Common tools for prognosis prediction include total kidney volume, Mayo classification and PROPKD/genetic score. Screening and management of complications such as hypertension, proteinuria, urological infections, intracranial aneurysms, are also crucial for improving outcome. We suggest that the optimal management strategies of patients with ADPKD include general medical care, dietary recommendations and ADPKD-specific treatments. Key points include rigorous blood pressure control, dietary sodium restriction and Tolvaptan use, whereas the evidence for somatostatin analogues and mammalian target of rapamycin (mTOR) inhibitors remains limited. In summary, we outline an individualized care plan emphasizing careful monitoring of disease progression and highlight the need for shared decision-making among these patients.

Co-design of a question prompt list about pregnancy and childbearing for women with polycystic kidney disease: an exploratory sequential mixed-methods study

BACKGROUND

Although women with polycystic kidney disease (PKD) generally have healthy pregnancies and babies, pregnancy is associated with a greater risk of maternal complications and requires planning and management of their condition. Given these possible complications, routine communication about childbearing between women with PKD and their treating team is important. A question prompt list (QPL), a structured list of questions used by patients during consultations with healthcare providers, may be beneficial in assisting women with PKD to discuss their childbearing concerns with, and seek related information from, their treating team. The aims of this study were to co-design a QPL about pregnancy and childbearing for women with PKD, and evaluate its comprehensibility, salience, and acceptability.

METHODS

An exploratory sequential mixed-methods study of women of reproductive age with PKD living in Australia, using an experience-based co-design approach with two phases. Women were recruited from a metropolitan public health service and via social media and invited to complete an anonymous online survey about the development of the PKD QPL (phase one) and participate in an online discussion group about its refinement (phase two).

RESULTS

Sixteen women completed the development survey and seven participated in the evaluation discussion group. Participants reported that women with PKD would value and use a QPL to prompt discussions with and seek further information about pregnancy and childbearing from their healthcare providers. Women identified four main topics for the QPL: 'thinking about having a baby', 'pregnancy', 'my medications' and 'after my baby is born'. Within each section a series of questions was developed. Based on the findings, a QPL about pregnancy and childbearing for women with PKD was co-designed.

CONCLUSIONS

Women with PKD often find it difficult to access information and have discussions with their health care providers about pregnancy and childbearing. The PKD QPL co-designed in this study was perceived to be an acceptable tool which will, from the perspectives of participants, assist women with PKD to access information more easily about pregnancy, childbearing and PKD; ask more targeted questions of their treating team; and make informed childbearing decisions.

Pregnancy in Autosomal Dominant Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disorder occurring in approximately 1:1000 individuals. ADPKD is characterized by gradual cyst expansion and kidney enlargement and is a slowly progressive disorder where patients typically initiate renal replacement therapy in the sixth decade of life. The vast majority of women with ADPKD become pregnant in the third or fourth decade, often before knowing that they have ADPKD, in the setting of normal kidney function or chronic kidney disease Stage 1. In ADPKD, pregnancy outcomes for mother and baby differ from the general population, and long-term consequences of maternal complications from pregnancy are common in ADPKD. In the current era of genetic testing, options to consider pre-implantation genetic screening are becoming more available. This chapter will review renal physiologic and anatomic changes that occur in pregnancy, the potential impact of ADPKD on maternal and fetal outcomes, medical management during pregnancy, the impact of pregnancy on long-term outcomes in women with ADPKD, and options for families with ADPKD planning to undergo pregnancy with regard to genetic testing.

Necrozoospermia: The tree that hides the forest

BACKGROUND

Necrozoospermia is a condition found in 0.2 to 0.4 % of male infertility cases. The causes of necrozoospermia are multiple: they can be related to testicular and/or post-testicular damage. Additionally, these causes most often involve the production of reactive oxygen species (ROS) and/or sperm DNA fragmentation (SDF) which can reduce the chances of spontaneous pregnancy or affect the outcome of assisted reproductive technologies.

OBJECTIVE

To focus on potential etiologies of necrozoospermia, its diagnosis and its therapeutic management especially before the employment of ICSI.

METHODS

Authors searched PubMed/Medline, Web of Science, Cochrane Library, Google and Institutional websites for medical subheading terms and free text words referred to "necrozoospermia", "sperm vitality", "sperm viability", "sperm DNA fragmentation" and "ICSI".

RESULTS

We identified twelve main etiologies of necrozoospermia responsible for either a decrease of sperm vitality, a mild a moderate or a severe necrozoospermia. In case of a confirmed decreased vitality, a thorough check-up should be conducted and if available, etiological treatment should be proposed. Therapeutic management could also include repeated ejaculations, drug treatments, the use of ICSI with ejaculated or surgically extracted spermatozoa in case of a non-treatable necrozoospermia.

DISCUSSION AND CONCLUSION

The potential causes of necrozoospermia should be investigated because many of them could be corrected, thus avoiding the use of ICSI. Moreover, if ICSI procedure remains necessary, the therapeutic management of necrozoospermia could also improve the chances of success by reducing oxidative stress and/or sperm DNA fragmentation. This article is protected by copyright. All rights reserved.

Rapidly Progressing to ESRD in an Individual with Coexisting ADPKD and Masked Klinefelter and Gitelman Syndromes

Autosomal dominant polycystic kidney disease (ADPKD) is the most common monogenetic hereditary renal disease, promoting end-stage renal disease (ESRD). Klinefelter syndrome (KS) is a consequence of an extra copy of the X chromosome in males. Main symptoms in KS include hypogonadism, tall stature, azoospermia, and a risk of cardiovascular diseases, among others. Gitelman syndrome (GS) is an autosomal recessive disorder caused by SLC12A3 variants, and is associated with hypokalemia, hypomagnesemia, hypocalciuria, normal or low blood pressure, and salt loss. The three disorders have distinct and well-delineated clinical, biochemical, and genetic findings. We here report a male patient with ADPKD who developed early chronic renal failure leading to ESRD, presenting with an intracranial aneurysm and infertility. NGS identified two de novo PKD1 variants, one known (likely pathogenic), and a previously unreported variant of uncertain significance, together with two SLC12A3 pathogenic variants. In addition, cytogenetic analysis showed a 47, XXY karyotype. We investigated the putative impact of this rare association by analyzing possible clinical, biochemical, and/or genetic interactions and by comparing the evolution of renal size and function in the proband with three age-matched ADPKD (by variants in PKD1) cohorts. We hypothesize that the coexistence of these three genetic disorders may act as modifiers with possible synergistic actions that could lead, in our patient, to a rapid ADPKD progression.

Curcumin supplementation in pediatric patients: A systematic review of current clinical evidence

This systematic review was designed to determine the clinical efficacy and safety of curcumin supplementation for pediatric patients based on clinical trials in children. We systematically searched electronic databases including PubMed, EMBASE, Web of Science, and Scopus for all studies that investigated curcumin administration in the pediatric population without any time frame limitation. Finally, we identified 16 studies for this review. Clinical efficacy and safety of curcumin were assessed in children with inflammatory and immune disorders (including asthma, inflammatory bowel disease (IBD), and juvenile idiopathic arthritis (JIA)), metabolic disorders, autosomal dominant polycystic kidney disease (ADPKD), cystic fibrosis (CF), tetralogy of Fallot (TOF), and infectious diseases. Curcumin was administered in a wide range of doses (45 mg-4,000 mg daily) and durations (2-48 weeks). Overall, curcumin was well tolerated in all studies and improved the severity of inflammatory and immune disorders and metabolic diseases. However, more studies are needed to clarify the role of curcumin supplementation among children with ADPKD, CF, TOF, and infectious diseases. Because of substantial heterogeneity in methodological quality, design, outcomes, dose, duration of intake, formulations, and study populations across studies, no quantitative analysis was performed. Additional large-scale, randomized, placebo-controlled clinical trials are needed to confirm the results of the conducted studies.

Genetic testing, ultrasonography and preimplantation genetic testing of men with autosomal dominant polycystic kidney disease in Hunan, China

The present study identified novel mutations in polycystic kidney disease (PKD) genes in China, determined the prevalence of cysts in the genital tract and accessory gonad in autosomal dominant PKD (ADPKD) patients, correlated these genes with ADPKD and male infertility and investigated whether male infertility associated with ADPKD affected the clinical outcomes in a preimplantation genetic testing (PGT) cycle cohort. This study was a cross-sectional study. Twenty-four unrelated men with ADPKD recruited from the Reproductive and Genetic Hospital of CITIC-Xiangya in China were investigated between January 2019 and December 2020. A total of 24 variations were identified in 22 patients, including 23, 1 and 0 variations in PKD1, PKD2 and GANAB, respectively. Genital tract and accessory gonadal cysts were significant dependent variables for male infertility. A diagnosis was made in 87.04% (94/108) and 51.85% (56/108) of the embryos for ADPKD and PGT-A respectively. Clinical pregnancy reached 72.73% per embryo transfer and 84.21% per patient. We identified a group of novel mutations in PKD genes, which enriches the PKD mutation spectrum. Although genital tract and accessory gonadal cysts greatly influence the fertility of men with ADPKD, they have minimal clinical consequences on pregnancy by intracytoplasmic sperm injection (ICSI) and PGT.

The Sonographic Appearance of Seminal Megavesicles, an Association With Autosomal Dominant Polycystic Kidney Disease: A Series Review

Megavesicles are an uncommon diagnostic finding during sonography of the bladder, especially when the examination is performed transabdominally. Although megavesicles are more likely seen with transrectal ultrasonography, computed tomogram (CT), vesiculography, or magnetic resonance imaging (MRI), it has been noted during transabdominal sonography for patients suffering from autosomal dominant polycystic kidney disease (ADPKD). When seminal vesicles become dilated, they are often visualized during transabdominal sonography. Two patient cases are provided of seminal megavesicles, associated with ADPKD and have documented sonographic findings. Both patient cases of megavesicles were discovered incidentally during the course of a renal sonogram. The importance of these diagnostic findings and the possible pathogenesis are provided.

Sperm ion channels and transporters in male fertility and infertility

Mammalian sperm cells must respond to cues originating from along the female reproductive tract and from the layers of the egg in order to complete their fertilization journey. Dynamic regulation of ion signalling is, therefore, essential for sperm cells to adapt to their constantly changing environment. Over the past 15 years, direct electrophysiological recordings together with genetically modified mouse models and human genetics have confirmed the importance of ion channels, including the principal Ca²⁺-selective plasma membrane ion channel CatSper, for sperm activity. Sperm ion channels and membrane receptors are attractive targets for both the development of contraceptives and infertility treatment drugs. Furthermore, in this era of assisted reproductive technologies, understanding the signalling processes implicated in defective sperm function, particularly those arising from genetic abnormalities, is of the utmost importance not only for the development of infertility treatments but also to assess the overall health of a patient and his children. Future studies to improve reproductive health care and overall health care as a function of the ability to reproduce should include identification and analyses of gene variants that underlie human infertility and research into fertility-related molecules.

Factors influencing the clinical outcome of preimplantation genetic testing for polycystic kidney disease

STUDY QUESTION

What are the factors influencing the success rate for couples undergoing preimplantation genetic testing (PGT) for polycystic kidney disease (PKD)?

SUMMARY ANSWER

In our study cohort, the live birth delivery rate is significantly associated with female age while the male infertility accompanying autosomal dominant PKD (ADPKD) does not substantially affect the clinical outcome.

WHAT IS KNOWN ALREADY

While women with ADPKD have no specific fertility problems, male ADPKD patients may present with reproductive system abnormalities and infertility.

STUDY DESIGN, SIZE, DURATION

This retrospective cohort study involves 91 PGT cycles for PKD for 43 couples (33 couples for PKD1, 2 couples for PKD2 and 8 couples for autosomal recessive PKD (ARPKD)) from January 2005 until December 2016 with follow-up of transfers until end of 2017.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Sixteen single-cell clinical tests for PKD based on multiplex PCR of short tandem repeat markers, with or without a specific mutation were developed and applied for diagnosis of 584 Day 3 cleavage stage embryos. In 18 couples, the male partner was affected with ADPKD (=Group A) and 12 of them had a documented infertility status. Group A underwent 52 cycles to oocyte retrieval. For 18 other couples, the female partner was affected with ADPKD (=Group B) and four male partners from this group had a documented history of infertility. This group underwent 31 cycles to OR.

MAIN RESULTS AND THE ROLE OF CHANCE

Genetic analysis resulted in 545 embryos (93.3%) with a diagnosis, of which 215 (36.8%) were genetically transferable. Transfer of 74 embryos in 53 fresh cycles and of 34 cryopreserved embryos in 33 frozen-warmed embryo transfer cycles resulted in a live birth delivery rate of 38.4% per transfer with 31 singleton live births, two twin live births and one ongoing pregnancy. The observed cumulative delivery rate was 57.8% per couple after five treatment cycles. Thirty cryopreserved embryos still remain available for transfer. The clinical pregnancy rate per transfer (fresh + frozen; 45.9% in group A versus 60.0% in group B, P < 0.05) and the live birth delivery rate per transfer (fresh + frozen; 27.0% in group A versus 42.9% in group B, P < 0.05) was significantly lower for couples with the male partner affected with ADPKD compared with couples with the female partner affected with ADPKD. However, a multivariate logistic regression analysis showed that only female age was associated with live birth delivery rate (odds ratio = 0.87; 95% CI: 0.77-0.99; P = 0.032).

LIMITATIONS, REASONS FOR CAUTION

This study is based on retrospective data from a single centre with Day 3 one-cell and two-cell biopsy. Further analysis of a larger cohort of PKD patients undergoing PGT is required to determine the impact of male infertility associated with ADPKD on the cumulative results.

WIDER IMPLICATIONS OF THE FINDINGS

Knowledge about factors affecting the clinical outcome after PGT can be a valuable tool for physicians to counsel PKD patients about their reproductive options. Males affected with ADPKD who suffer from infertility should be advised to seek treatment in time to improve their chances of conceiving a child.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was obtained. There are no competing interests to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Combined Preimplantation Genetic Testing for Autosomal Dominant Polycystic Kidney Disease: Consequences for Embryos Available for Transfer

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary kidney disease and presents with genetic and clinical heterogeneity. ADPKD can also manifest extra-renally, and seminal cysts have been associated with male infertility in some cases. ADPKD-linked male infertility, along with female age, have been proposed as factors that may influence the clinical outcomes of preimplantation genetic testing (PGT) for monogenic disorders (PGT-M). Large PGT for aneuploidy assessment (PGT-A) studies link embryo aneuploidy to increasing female age; other studies suggest that embryo aneuploidy is also linked to severe male-factor infertility. We aimed to assess the number of aneuploid embryos and the number of cycles with transferable embryos in ADPKD patients after combined-PGT. The combined-PGT protocol, involving PGT-M by PCR and PGT-A by next-generation sequencing, was performed in single trophectoderm biopsies from 289 embryos in 83 PGT cycles. Transferable embryos were obtained in 69.9% of cycles. The number of aneuploid embryos and cycles with transferable embryos did not differ when the male or female had the ADPKD mutation. However, a significantly higher proportion of aneuploid embryos was found in the advanced maternal age (AMA) group, but not in the male factor (MF) group, when compared to non-AMA and non-MF groups, respectively. Additionally, no significant differences in the percentage of cycles with transferable embryos were found in any of the groups. Our results indicate that AMA couples among ADPKD patients have an increased risk of aneuploid embryos, but ADPKD-linked male infertility does not promote an increased aneuploidy rate.

Transcriptome profiling of porcine testis tissue reveals genes related to sperm hyperactive motility

BACKGROUND

Sperm hyperactive motility has previously been shown to influence litter size in pigs, but little is known about the underlying biological mechanisms. The aim of this study was to use RNA sequencing to investigate gene expression differences in testis tissue from Landrace and Duroc boars with high and low levels of sperm hyperactive motility. Boars with divergent phenotypes were selected based on their sperm hyperactivity values at the day of ejaculation (day 0) (contrasts (i) and (ii) for Landrace and Duroc, respectively) and on their change in hyperactivity between day 0 and after 96 h liquid storage at 18 °C (contrast (iii)).

RESULTS

RNA sequencing was used to measure gene expression in testis. In Landrace boars, 3219 genes were differentially expressed for contrast (i), whereas 102 genes were differentially expressed for contrast (iii). Forty-one differentially expressed genes were identified in both contrasts, suggesting a functional role of these genes in hyperactivity regardless of storage. Zinc finger DNLZ was the most up-regulated gene in contrasts (i) and (iii), whereas the most significant differentially expressed gene for the two contrasts were ADP ribosylation factor ARFGAP1 and solute carrier SLC40A1, respectively. For Duroc (contrast (ii)), the clustering of boars based on their gene expression data did not reflect their difference in sperm hyperactivity phenotypes. No results were therefore obtained for this breed. A case-control analysis of variants identified in the Landrace RNA sequencing data showed that SNPs in NEU3, CHRDL2 and HMCN1 might be important for sperm hyperactivity.

CONCLUSIONS

Differentially expressed genes were identified in Landrace boars with high and low levels of sperm hyperactivity at the day of ejaculate collection and high and low change in hyperactivity after 96 h of sperm storage. The results point towards important candidate genes, biochemical pathways and sequence variants underlying sperm hyperactivity in pigs.

Management of Autosomal Dominant Polycystic Kidney Disease (ADPKD) During Pregnancy: Risks and Challenges

Autosomal dominant polycystic kidney disease (ADPKD) affects up to 1 in 1000 people. The disease is characterized by the progressive development of cysts throughout the renal parenchyma due to inherited pathogenic variants in genes including PKD1 or PKD2 and eventually leads to gradual loss of renal function, along with manifestations in other organ systems such as hepatic cysts and intracranial aneurysms. ADPKD management has advanced considerably in recent years due to genetic testing availability, pre-implantation genetic diagnosis technology and new therapeutic agents. Renal disease in pregnancy is recognised as an important risk factor for adverse maternal and fetal outcome. Women with ADPKD and health professionals face multiple challenges in optimising outcomes during the pre-pregnancy, pregnancy and post-partum periods.

A novel frameshift PKD1 mutation in a Chinese patient with autosomal dominant polycystic kidney disease and azoospermia: A case report

Autosomal dominant polycystic kidney disease (ADPKD) is primarily caused by mutations in polycystin 1, transient receptor potential channel interacting (PKD1) and PKD2, and characterized by numerous cysts in various organs, primarily the kidneys and liver. The present case report is on a 33-year-old Chinese male patient who suffered from abdominal pain and hypertension, and presented with long-term infertility. Laboratory tests indicated that the patient had a normal renal function, while abdominal computed tomography demonstrated that the patient had enlarged kidneys with a volume of 1,127.21 cm³. In a semen analysis, no sperm was detected, while a subsequent testicular biopsy analysis demonstrated numerous mature sperms with progressive motility which suggests that the cysts of the epididymis and the dilated seminal vesicles may have obstructed the ejaculation of semen. Genetic testing identified that a novel missense mutation (c.9053delT) that was responsible for the disease. ADPKD has various disease severities, which depend on whether there is a PKD1 or PKD2 mutation and whether the mutation impairs the function of the polycystin protein. Therefore, genetic testing is important for the clinical diagnosis and prognosis of ADPKD patients, as well as prenatal diagnosis.

Role of transient receptor potential channels in regulating spermatozoa functions: A mini-review

Flagellar navigation along the genital tract of male and female in spermatozoa is accomplished through a number of biological, physiological, biochemical, and electrophysiological alterations in spermatozoa. These alterations are highly precise, dynamic, and regulated through a number of ion channels along with their associated pathways. Beating of flagella along with intracellular metabolism of spermatozoa is associated with fluxing of Ca++ as well as release of Ca++ from different sources. Calcium fluxing through the spermatozoa is mediated through sperm-specific calcium channel and also through transient receptor potential (TRP) channels which are diversified multifamily of ion channels which are activated through a number of extracellular agents such as pH, temperature, chemicals, and pathogens. Research has shown the dynamic role of TRP channels in regulating sperm functions such as sperm chemotaxis, rheotaxis, thermotaxis, and eventually fertilization. Diversified forms of TRP and their involvement in regulation of sperm function opens new horizons of understanding of the sperm function and, in specific, issues related to infertility. This mini-review is an attempt to draw some insights into the action of TRP channels in regulating sperm fertility competence through both calcium-dependent and calcium-independent mechanisms.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

Preimplantation Genetic Diagnosis Counseling in Autosomal Dominant Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common hereditary forms of chronic kidney disease. Mutations within PKD1 or PKD2 lead to innumerable fluid-filled cysts in the kidneys and in some instances, end-stage renal disease (ESRD). Affected individuals have a 50% chance of passing the mutation to each of their offspring. Assisted reproductive technology using preimplantation genetic diagnosis (PGD) allows these individuals to reduce this risk to 1% to 2%. We assess the disease burden of 8 individuals with ADPKD who have undergone genetic testing in preparation for PGD. Clinical features that predict high risk for progression to ESRD in patients with ADPKD include genotype, early onset of hypertension, a urologic event before age 35 years, and a large height-adjusted total kidney volume. Patients may have a family history of intracranial aneurysms or complications involving hepatic cysts, which may further influence the decision to pursue PGD. We also explore the cost, risks, and benefits of using PGD. All patients with ADPKD of childbearing potential, regardless of risk for progression to ESRD or risk for a significant disease burden, will likely benefit from genetic counseling.

[Necrozoospermia: From etiologic diagnosis to therapeutic management]

This review describes necrospermia, its diagnosis, causes and management. Sperm vitality is commonly assessed in the laboratory of reproductive biology, with the eosin test or with the hypo-osmotic swelling test. Necrospermia is defined by a percentage of living spermatozoa inferior to 58%, and can be related to male infertility. Several pathological mechanisms may be involved and can be classified either in testicular causes (hyperthyroidism, local hyperthermia, varicocele), or post-testicular causes (epididymal necrospermia, dysregulation of seminal plasma, adult polycystic kidney disease, vasectomy reversal, anti-sperm antibodies) or both (infection, toxic, age, spinal cord injury). The first treatment is to correct the underlying cause, if possible. Repetitive ejaculation has demonstrated to be effective as well. Many drugs would also improve the sperm vitality (antioxidants, non-and-steroidal anti-inflammatory drugs) but there is currently no guideline to recommend their use. With necrospermia, fertilization rates are lower but in vitro fertilization (IVF) with Intracytoplasmic sperm injection (ICSI) improves the chances of conception.

Managing pregnancy in chronic kidney disease: improving outcomes for mother and baby

Parenthood is a central focus for women with chronic kidney disease, but raises important fears and uncertainties about risks to their own and their baby’s health. Pregnancy in women with background kidney disease, women receiving dialysis, or those with a functioning kidney transplant poses a challenging clinical scenario, associated with high maternal–fetal morbidity and potential impact on maternal renal health. Improvements in care over recent decades have led to a paradigm shift with cautious optimism and growing interest regarding pregnancies in women with chronic kidney disease. In this review, we discuss obstetric and renal outcomes, and practical aspects of management of pregnancy in this complex cohort.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

Fetal imaging prompts maternal diagnosis: autosomal dominant polycystic kidney disease

Autosomal dominant polycystic kidney disease (ADPKD) is a common inherited disorder. Ultrasound (US) findings can include enlarged echogenic kidneys in utero and cysts in multiple organs in adults. Though a highly penetrant disease, due to varied clinical expression and the typical late onset of symptoms, reproductive-aged women may not know their carrier status. We present two cases in which fetal US findings suggested ADPKD and additional evaluation identified likely maternal ADPKD as well.

Sperm mRNAs and microRNAs as candidate markers for the impact of toxicants on human spermatogenesis: an application to tobacco smoking

Spermatozoa contain a complex population of RNAs including messenger RNAs (mRNAs) and small RNAs such as microRNAs (miRNA). It has been reported that these RNAs can be used to understand the mechanisms by which toxicological exposure affects spermatogenesis. The aim of our study was to compare mRNA and miRNA profiles in spermatozoa from eight smokers and eight non-smokers, and search for potential relationships between mRNA and miRNA variation. All men were selected based on their answers to a standard toxic exposure questionnaire, and sperm parameters. Using mRNA and miRNA microarrays, we showed that mRNAs from 15 genes were differentially represented between smokers and non-smokers (p<0.01): five had higher levels and 10 lower levels in the smokers. For the microRNAs, 23 were differentially represented: 16 were higher and seven lower in the smokers (0.004≤p<0.01). Quantitative RT-PCR confirmed the lower levels in smokers compared to non-smokers for hsa-miR-296-5p, hsa-miR-3940, and hsa-miR-520d-3p. Moreover, we observed an inverse relationship between the levels of microRNAs and six potential target mRNAs (B3GAT3, HNRNPL, OASL, ODZ3, CNGB1, and PKD2). Our results indicate that alterations in the level of a small number of microRNAs in response to smoking may contribute to changes in mRNA expression in smokers. We conclude that large-scale analysis of spermatozoa RNAs can be used to help understand the mechanisms by which human spermatogenesis responds to toxic substances including those in tobacco smoke.

Seminal megavesicle in autosomal dominant polycystic kidney disease

Retrospective analysis of 99 male autosomal dominant polycystic kidney disease (ADPKD) patients compared to an age-matched control population showed seminal vesicle ectasia >10 mm (megavesicle) in 23% (23/99) of ADPKD patients that was not present in any controls (P<.0001). Median (range) seminal vesicle convoluted tubule diameter in ADPKD patients was 4.2 (1.7-30) mm compared to 3.1 (1.7-6.8) mm in controls (P<.0001). Discrete cysts were identified in four ADPKD patients but in none of the control population (P=.12). Seminal megavesicles may explain the infertility sometimes observed in male ADPKD patients.

Novel roles of Pkd2 in male reproductive system development

Autosomal dominant polycystic kidney disease (ADPKD) is one of the most common inherited genetic diseases, caused by mutations in PKD1 and/ or PKD2. Infertility and reproductive tract abnormalities in male ADPKD patients are very common and have higher incidence than in the general population. In this work, we reveal novel roles of Pkd2 for male reproductive system development. Disruption of Pkd2 caused dilation of mesonephric tubules/efferent ducts, failure of epididymal coiling, and defective testicular development. Deletion of Pkd2 in the epithelia alone was sufficient to cause reproductive tract defects seen in Pkd2(-/-) mice, suggesting that epithelial Pkd2 plays a pivotal role for development and maintenance of the male reproductive tract. In the testis, Pkd2 also plays a role in interstitial tissue and testicular cord development. In-depth analysis of epithelial-specific knockout mice revealed that Pkd2 is critical to maintain cellular phenotype and developmental signaling in the male reproductive system. Taken together, our data for the first time reveal novel roles for Pkd2 in male reproductive system development and provide new insights in male reproductive system abnormality and infertility in ADPKD patients.

Pkd1 is required for male reproductive tract development

Reproductive tract abnormalities and male infertility have higher incidence in ADPKD patients than in general populations. In this work, we reveal that Pkd1, whose mutations account for 85% of ADPKD cases, is essential for male reproductive tract development. Disruption of Pkd1 caused multiple organ defects in the murine male reproductive tract. The earliest visible defect in the Pkd1(-/-) reproductive tract was cystic dilation of the efferent ducts, which are derivatives of the mesonephric tubules. Epididymis development was delayed or arrested in the Pkd1(-/-) mice. No sign of epithelial coiling was seen in the null mutants. Disruption of Pkd1 in epithelium alone using the Pax2-cre mice was sufficient to cause efferent duct dilation and coiling defect in the epididymis, suggesting that Pkd1 is critical for epithelium development and maintenance in male reproductive tract. In-depth analysis showed that Pkd1 is required to maintain tubulin cytoskeleton and important for Tgf-β/Bmp signal transduction in epithelium of male reproductive tract. Altogether, our results for the first time provide direct evidence for developmental roles of Pkd1 in the male reproductive tract and provide new insights in reproductive tract abnormalities and infertility in ADPKD patients.

Renal disease and hypertension in pregnancy

Because women are becoming pregnant at a later age, hypertension is more commonly encountered in pregnancy. In addition, with increasing numbers of young women living with renal transplants and kidney disease, it is important for physicians to be aware of the effects of pregnancy on these diseases. A multidisciplinary approach is essential to assess and care for pregnant women with kidney disease. Pre-pregnancy counselling should be offered to all women with chronic kidney disease. A review of medication to avoid teratogenicity and optimise the disease prior to conception is the ideal. Pregnancy may be the first medical review for a young woman, who may present with a previously undiagnosed renal problem.

Stage 1 chronic kidney disease in pregnancy

Stage 1 chronic kidney disease (CKD) is defined by normal renal function, an estimated glomerular filtration rate of >90 mL/minute and abnormalities on urinalysis or ultrasound. These patients when pregnant are commonly seen, and diagnoses include diabetic nephropathy, glomerulonephritis, nephrolithiasis, reflux nephropathy, polycystic kidney disease and lupus nephritis. Underlying renal disease may also first become apparent in pregnancy, posing a diagnostic challenge. Patients tend to do well, but all need to be closely monitored particularly for hypertension and pre-eclampsia, which are more common in patients with stage 1 CKD overall. Relevant pregnancy outcomes may be divided into maternal (e.g. renal deterioration, nephrolithiasis, lupus flare, urinary infection or pyelonephritis), fetal (e.g. growth restriction, fetal death or stillbirth) and obstetric (e.g. hypertension, pre-eclampsia, preterm delivery, thrombosis). Specific diagnoses, their clinical features, management strategies and prognosis are reviewed.

Low-dose oral sirolimus and the risk of menstrual-cycle disturbances and ovarian cysts: analysis of the randomized controlled SUISSE ADPKD trial

Sirolimus has been approved for clinical use in non proliferative and proliferative disorders. It inhibits the mammalian target of rapamycin (mTOR) signaling pathway which is also known to regulate ovarian morphology and function. Preliminary observational data suggest the potential for ovarian toxicity but this issue has not been studied in randomized controlled trials. We reviewed the self-reported occurrence of menstrual cycle disturbances and the appearance of ovarian cysts post hoc in an open label randomized controlled phase II trial conducted at the University Hospital Zürich between March 2006 and March 2010. Adult females with autosomal dominant polycystic kidney disease, an inherited kidney disease not known to affect ovarian morphology and function, were treated with 1.3 to 1.5 mg sirolimus per day for a median of 19 months (N = 21) or standard care (N = 18). Sirolimus increased the risk of both oligoamenorrhea (hazard ratio [HR] 4.3, 95% confidence interval [CI] 1.1 to 29) and ovarian cysts (HR 4.4, CI 1.1 to 26); one patient was cystectomized five months after starting treatment with sirolimus. We also studied mechanisms of sirolimus-associated ovarian toxicity in rats. Sirolimus amplified signaling in rat ovarian follicles through the pro-proliferative phosphatidylinositol 3-kinase pathway. Low dose oral sirolimus increases the risk of menstrual cycle disturbances and ovarian cysts and monitoring of sirolimus-associated ovarian toxicity is warranted and might guide clinical practice with mammalian target of rapamycin inhibitors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00346918.

Male infertility and adult polycystic kidney disease--revisited: case report and current literature review

Adult polycystic kidney disease (APKD) is one of the most common inherited disorders affecting one in 800-1000 live births. Extra-renal manifestation of APKD is not uncommon. Cysts involving the male and female reproductive system have been reported. However, fertility is affected only in male subjects. Among cysts involving the reproductive system, seminal vesicle cysts have been reported to be the most common. The effect of seminal vesicle cysts on male fertility has been controversial. Current literature reports that majority of men remain fertile. However, uraemia and its implications on fertility and abnormal semen parameters in men with seminal vesicle cysts must be taken into consideration. We herein present two patients with APKD with contrasting semen parameters and also review the current literature.

Polycystic diseases in visceral organs

Primary cilia are nonmotile, microtubule-based, antenna-like organelles projecting from the apical surface of most mammalian cells. Elegant studies have established the importance of ciliary structure and function in signal transduction and the sensory roles of cilia in maintaining healthy cellular state. In particular, dysfunctional cilia have been implicated in a large number of diseases mainly characterized by the presence of fluid-filled cysts in various organs. Aside from polycystic kidney disease (PKD), however, the roles of cilia in polycystic liver disease (PLD), polycystic pancreas disease (PPD), and polycystic ovarian syndrome (PCOS) are still very vague. In addition, although gender and sex hormones are known to regulate cyst formation, their roles in regulating physiological functions of cilia need to be further explored.

[Pregnancy and kidney diseases]

The prevalence of chronic kidney disease in women of childbearing age reaches approximately 0.2%. Under physiological conditions pregnancy results in important hemodynamic changes on the maternal organism. In the case of chronic kidney disease these adaptations often are only partial. Physiological changes of immune response during pregnancy may contribute to the progress of renal disease. Regardless of the underlying kidney disease, one can assume that the better the glomerular filtration rate and blood pressure are the more favorable the course of pregnancy will be with the chance for a healthy child and stable renal function. To achieve this goal, a close interaction is required between gynecologist, nephrologist, and other specialists in a center with appropriate experience.

Extrarenal manifestations of autosomal dominant polycystic kidney disease

Although asymptomatic in most patients, extrarenal manifestations of ADPKD may become more clinically relevant with the increasing life expectancy of affected patients. They mainly encompass cysts in other organs than the kidney (liver: 94%, seminal vesicle: 40%, pancreas: 9%, arachnoid membrane: 8%, and spinal meningeal, 2%) and connective tissue abnormalities (mitral valve prolapse: 25%, intracranial aneurysms: 8%, and abdominal hernia: 10%). Their recognition may spare the patient from other, useless investigations (eg, when an arachnoid cyst is incidentally found) or lead to the implementation of prophylactic or therapeutic measures (eg, screening, sometimes followed by the treatment of an asymptomatic intracranial aneurysm in at-risk patients, or, in the presence of a severe polycystic liver disease, avoidance from estrogens and treatment aimed to slow cyst growth).

The CIL-1 PI 5-phosphatase localizes TRP Polycystins to cilia and activates sperm in C. elegans

BACKGROUND

C. elegans male sexual behaviors include chemotaxis and response to hermaphrodites, backing, turning, vulva location, spicule insertion, and sperm transfer, culminating in cross-fertilization of hermaphrodite oocytes with male sperm. The LOV-1 and PKD-2 transient receptor potential polycystin (TRPP) complex localizes to ciliated endings of C. elegans male-specific sensory neurons and mediates several aspects of male mating behavior. TRPP complex ciliary localization and sensory function are evolutionarily conserved. A genetic screen for C. elegans mutants with PKD-2 ciliary localization (Cil) defects led to the isolation of a mutation in the cil-1 gene.

RESULTS

Here, we report that a phosphoinositide (PI) 5-phosphatase, CIL-1, regulates TRPP complex ciliary receptor localization and sperm activation. cil-1 does not regulate the localization of other ciliary proteins, including intraflagellar transport (IFT) components, sensory receptors, or other TRP channels in different cell types. Rather, cil-1 specifically controls TRPP complex trafficking in male-specific sensory neurons and does so in a cell-autonomous fashion. In these cells, cil-1 is required for normal PI(3)P distribution, indicating that a balance between PI(3,5)P2 and PI(3)P is important for TRPP localization. cil-1 mutants are infertile because of sperm activation and motility defects. In sperm, the CIL-1 5-phosphatase and a wortmannin-sensitive PI 3-kinase act antagonistically to regulate the conversion of sessile spermatids into motile spermatozoa, implicating PI(3,4,5)P3 signaling in nematode sperm activation.

CONCLUSION

Our studies identify the CIL-1 5-phosphatase as a key regulator of PI metabolism in cell types that are important in several aspects of male reproductive biology.

Male infertility associated with adult dominant polycystic kidney disease: a case series

INTRODUCTION

Although described earlier, the association of male infertility with adult dominant polycystic kidney disease (ADPKD) is quite rare and unfamiliar to some of the multidisciplinary team members caring for affected men.

MATERIALS AND METHODS

Infertile men diagnosed to have ADPKD were evaluated by clinical characteristics including testis volume, as well as serum hormone levels, semen analysis, and transrectal ultrasonography (TRUS) because of low volume ejaculate.

RESULTS

Semen analysis revealed low-normal volume, normal pH, and azoospermia/virtual azoospermia. Serum hormones were within the normal range. Transrectal ultrasonography demonstrated cystic dilatation of the seminal vesicles in all three men.

CONCLUSION

Patients should be referred for andrological evaluation of a presentation similar to obstructive azoospermia. Their potential to achieve paternity by surgical sperm retrieval combined with assisted reproductive technology is another example of cooperation between andrologists and gynecologists.

Gene expression in early and progression phases of autosomal dominant polycystic kidney disease

Background

Little is known about the genes involved in the initial cyst formation and disease progression in autosomal dominant polycystic kidney disease (ADPKD); however, such knowledge is necessary to explore therapeutic avenues for this common inherited kidney disease.

Findings

To uncover the genetic determinants and molecular mechanisms of ADPKD, we analyzed 4-point time-series DNA microarrays from Pkd1^L3/L3 mice to generate high resolution gene expression profiles at different stages of disease progression. We found different characteristic gene expression signatures in the kidneys of Pkd1^L3/L3 mice compared to age-matched controls during the initial phase of the disease. By postnatal week 1, the Pkd1^L3/L3 kidney already had a distinctive gene expression pattern different from the corresponding normal controls.

Conclusion

The genes differentially expressed, either induced or repressed, in ADPKD are important in immune defense, cell structure and motility, cellular proliferation, apoptosis and metabolic processes, and include members of three pathways (Wnt, Notch, and BMP) involved in morphogenetic signaling. Further analysis of the gene expression profiles from the early stage of cystogenesis to end stage disease identified a possible gene network involved in the pathogenesis of ADPKD.