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Women and Alport Syndrome
Michelle Rheault, M.D.
Assistant Professor
Division of Pediatric Nephrology
University of Minnesota, USA
Disclosures
• None
Historical Perspective
• “The females have deafness and heamaturia and live to old age”- (Alport AC: Br Med J 1:504-506, 1927)
• “Females usually remain well throughout life…and only rarely have women died of the disease.”(Perkoff GT: Annu Rev Med 15:115-24, 1964)
Carrier Natural History Study• 195 families with known COL4A5 mutations
(349 women and girls)• Microscopic hematuria present in 95.5%• Proteinuria present in 75%• Hearing loss present in 28%• By age 40, 12% of carriers had reached
ESRD • By age 60, 30-40% of carriers had reached
ESRD
Jais, et al. JASN. 14:2603-2610, 2003
Probability of ESRD in Alport Carriers
Jais, et al. JASN. 14:2603-2610, 2003
Males
Females
Probability of Hearing Loss in Alport Carriers
Males
Females
Jais, et al. JASN. 14:2603-2610, 2003
Risk of ESRD in Alport Carriers with Hearing Loss
• The risk of ESRD is higher in female carriers with hearing loss (p=0.02)
Jais, et al. JASN. 14:2603-2610, 2003
no hearing loss
+ hearing loss
• Risk of ESRD greater if proteinuria present (p<0.001)
Jais, et al. JASN. 14:2603-2610, 2003
Proteinuria
No Proteinuria
Risk of ESRD in Alport Carriers with Proteinuria
What determines disease severity in Alport carriers?
• Mutation– Unlike males, there is no correlation between type
of mutation and rate of disease progression (Jais, et al. JASN. 14:2603-2610, 2003)
– No correlation in disease severity between males and females within the same family
• Modifier genes• X chromosome inactivation• ?
X-chromosome Inactivation
www.synapses.co.uk/genetics/tsg12.html
Case Reports• 19 year old female presented with
microscopic hematuria and nephrotic syndrome and reached ESRD by 30– Found to have 2 mutations in COL4A5 expressed
in >90% of both kidney and white blood cellsa
• 2 year old female with hematuria/proteinuria with hearing loss developing at age 14. Biopsy showed X-linked Alport syndrome– Found to have balanced translocation t(X;1)
(q22.3;p36.32) with preferential inactivation of the normal X chromosomeb
aGuo, et al., JCI. 95:1832-1837, 1995bIijima, et al., Pediatr Nephrol, DOI 10.1007/s00467-010-1514-1, 2010
• Hypothesis: The variability of renal outcome in carriers of XLAS is caused by random X-inactivation
• We used genetic tools in a mouse model of XLAS to test this hypothesis
X-inactivation in mice with XLAS
Group 2:Express more wild type COL4A5
Alport carrier
X
Group 1:Express moremutant COL4A5
Mouse strains thatskew X-inactivation
Rheault et. al., Nephrol Dial Transplant, 25:764-9, 2010
Preferential expression of wild type X-chromosome (group 2) in mice with COL4A5
mutation confers a survival advantage
Group 2
Group 1
P<0.001
Rheault et. al., unpublished observations
X inactivation and Alport Syndrome
• When tested directly in controlled genetic backgrounds, favorable X-inactivation increases survival and improves clinical parameters in female carriers of XLAS in mice
• X inactivation is not the only factor that influences disease severity
• Further research is needed
New European Registry Data
Temme, et al. Kidney international. 81:779-83, 2012
New European Registry Data
Temme, et al. Kidney international. 81:779-83, 2012
RAAS blockade is associated with delayed renal failure in heterozygous Alport patients
Temme, et al. Kidney international. 81:779-83, 2012
Treatment recommendations for heterozygous XLAS Alport females
• For females with proteinuria: start ACE inhibitor• For females with microalbuminuria: consider ACE
inhibitor if family history of early kidney failure or severe mutation
Kashtan, et al. Pediatr Nephrol. DOI 10.1007/s00467-012-2138-4, 2012
• We can’t predict which carriers are going to progress to ESRD
• Difficult balance between risk to donor and benefits for recipient
• Little long term data about outcomes in carriers after donation
Should Alport Carriers be Kidney Donors?
Should Alport Carriers be Kidney Donors?
• 3/6 donors developed hypertension
• 2/6 donors developed proteinuria
• Renal function declined significantly in 4/6 donors– -35% after 2 years– -25% after 3 years– -30% after 4 years– -60% after 14 years
Gross et. al., Nephrol Dial Transplant, 24:1626-30, 2009
• Alport carriers should be kidney donors of last resort
• Alport carriers with proteinuria or hearing loss should be excluded as kidney donors
• Alport carriers with only microscopic hematuria should be considered as donors only after careful counseling about risks and with close post-transplant monitoring
• Renal protective strategies for donors are needed (ACE inhibitors?)
• Future collaborative studies are needed
Should Alport Carriers be Kidney Donors?
Alport syndrome and pregnancy
• Case reports have been published suggesting increased risk of preterm delivery, decline in renal function, and increased proteinuria during pregnancy
• No good data exists on renal outcomes in Alport carriers after pregnancy
• Recommendation: Pregnant Alport carriers should have kidney function, blood pressure, and proteinuria monitored closely
Conclusions• Carriers of X-linked Alport syndrome are at risk
for ESRD– Higher risk of ESRD if proteinuria or hearing loss
present
• In a mouse model of X-linked Alport Syndrome, favorable X-inactivation increases survival and improves clinical parameters in carriers
• ACE inhibitors are associated with decreased risk of end stage kidney disease in Alport carriers
Acknowledgements• Alport Syndrome Foundation
• University of Minnesota– Yoav Segal– Cliff Kashtan– Stefan Kren– Will Thomas– Linda Hartich– Melanie Wall– Hector Mesa
• Texas A & M University– George Lees
• Pasteur Institute– Philip Avner