Genotype-phenotype correlations influence the response to angiotensin-targeting drugs in Japanese patients with male X-linked Alport syndrome

• DOI: 10.1016/j.kint.2020.06.038
• Publication Date: 2020-07-24T07:02:42Z
• Authors: Tomohiko Yamamura; Tomoko Horinouchi; China Nagano; Takashi Omori; Nana Sakakibara; Yuya Aoto; Shinya Ishiko; Koichi Nakanishi; Yuko Shima; Hiroaki Nagase; Hiroki Takeda; Rini Rossanti; Ming Juan Ye; Yoshimi Nozu; Shingo Ishimori; Takeshi Ninchoji; Hiroshi Kaito; Naoya Morisada; Kazumoto Iijima; Kandai Nozu
• Keywords: Alport syndrome

Early kidney failure in the hereditary type IV collagen disease, Alport syndrome, can be delayed by renin-angiotensin inhibitors. However, whether all patients and different genotypes respond equally well to this kidney-protective therapy remains unclear. Here, we performed a retrospective study on 430 with male X-linked syndrome examine relationships among prognosis, genotype, treatment effect large cohort of Japanese patients. We analyzed clinical features, genotype-phenotype correlation, survival period for treated or without As result, median was found at 35 years strong correlation. The age onset end stage disease (ESKD) significantly differed between inhibitors (over 50 versus 28 years, respectively). Moreover, these drugs ESKD truncating variants 12 extending from 16 years. Thus, our results confirmed correlation syndrome. Additionally, it suggested that could delay progression. Despite therapies, developed is characterized progressive renal dysfunction, sensory hearing loss, ocular abnormalities.1Alport A.C. Hereditary familial congenital haemorrhagic nephritis.Br Med J. 1927; 1: 504-506Crossref PubMed Scopus (467) Google Scholar, 2Kashtan C.E. thin glomerular basement membrane disease.J Am Soc Nephrol. 1998; 9: 1736-1750PubMed 3Kashtan Michael A.F. syndrome.Kidney Int. 1996; 50: 1445-1463Abstract Full Text PDF (154) Scholar caused defects network, major structural component membranes kidney, inner ear, eye. Six genetically distinct α-chains (α1–α6) have been identified. Pathogenic COL4A5 gene, which encodes α5 chain, are known cause (XLAS); XLAS present approximately 85% syndrome.4Kashtan X chromosome: implications diagnosis females.Nephrol Dial Transplant. 2007; 22: 1499-1505Crossref (37) Because mode inheritance, affected exhibited more severe phenotypes than female ones; correlations identified populations Europe United States.5Bekheirnia M.R. Reed B. 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Bertelson C.J. Liechti-Gallati S. al.An explanation phenotypic bearing partial deletions DMD locus.Genomics. 1988; 2: 90-95Crossref (863) Examining vital estimate perform genetic counseling, guide Although there no specific protective effects angiotensin-converting enzyme (ACEI) angiotensin receptor blockers (ARB) demonstrated several relatively cohorts.10Gross Licht C. Anders H.J. al.Early inhibition delays improves life expectancy.Kidney 2012; 81: 494-501Abstract (178) 11Temme Peters F. Lange al.Incidence nephroprotection RAAS heterozygous carriers X-chromosomal autosomal recessive mutations.Kidney 779-783Abstract (86) 12Zhang Y. Wang Ding al.Long-term ACE children syndrome.Pediatr 2016; 31: 67-72Crossref (13) Therefore, experts field recommended ACEI/ARB after XLAS.13Savige M. Gross al.Expert guidelines management nephropathy.J 2013; 24: 364-375Crossref (206) Scholar,14Nozu Nakanishi Abe al.A review characteristics backgrounds syndrome.Clin Exp 2019; 23: 158-168Crossref (44) best knowledge, analysis yet examining genotype treatment. Correlations reported pathogenic features loss expression membrane) membrane).15Hashimura Kaito H. al.Milder aspects men positive alpha5 chain.Kidney 2014; 85: 1208-1213Abstract Scholar,16Zhang X. Zhang variant further auditory males.Orphanet J Rare Dis. 13: 229Crossref (8) studies were small, larger cohorts should confirm findings. conducted large-scale XLAS; aims evaluate as various use ACEI and/or ARB, membrane). detailed based gene transcripts genotype-dependent response Mutation data obtained total participants (282 148 family members 269 families). only diagnoses (at time diagnosis) Table 1. testing 13 (range, 0–73 years). Proteinuria detected 238 (91%). Around 61 282 110 develop end-stage (ESRD). Specific changes (6%), whereas 77 (32%). mutational presented 2.Table 1Clinical diagnosisCharacteristicsMedian (yr) (range)13 (0–73)Clinical featuresN datan (%)Hematuria264262 (99)Proteinuria262238 (91)End-stage disease28261 (22)Hearing loss23877 (32)Ocular changes22913 (6) Open table new tab 2Mutational familiesCharacteristicsN (%)Transcript typeGlomerular membraneACEI/ARB treatmentTruncatingNontruncatingα5(IV)-positiveα5(IV)-negativeACEI/ARB (+)ACEI/ARB (−)Mutation types patients430 Nonsense mutation30 (7.0)300111127 Large rearrangement14 (3.3)––3565 Splicing variant71 (16.5)32368172812 Small deletion/insertion/duplication65 (15.1)21447242418 Missense mutation250 (58.1)025045256244Mutation families269 mutation19 (7.1) rearrangement13 (4.8) variant49 (18.2) deletion/insertion/duplication44 (16.4)Missense mutation144 (53.5)ACEI, inhibitor; blocker. ACEI, Eight excluded analyses because missing data. (age development ESRD) remaining 422 (95% confidence intervals: 32–40 Figure 1 presents curves mutation variants. ESRD differ patients, (P < 0.01) (Table 3). Specifically, highly significant (Supplementary S1). rearrangement, variant, rearrangement noted. each intervals, numbers patients) follows: 18 (16–27 30); (19–55 14); (23–34 69); 25 (20–45 =64); 40 (35–45 245) (Figure 1a; 3).Table 3Comparison mutationsGenotype (n)Median diseaseaThe developing using Kaplan-Meier method.All CI)Truncating CI, n)Nontruncating n)P valueAll35 (32–40)20 (18–23, 106)40eThe same number much greater genotypes, table. (35–42, 296)<0.01Nonsense (30)18 (16–27)18 (16–27, 30)–Large deletion/duplication (14)21 (19–55)––Splicing (65b5 2 somatic mosaicism, patient both normal aberrantly spliced transcript, not patients.)25 (23–30)23 (16–28, 32)28 (25–36, 33)<0.05Small deletion/insertion/duplication (63cOne he suspected having aberrant but mRNA analyzed.)26 (20–45)20 (15–24, 44)35 (25–65, 19)<0.05Missense (244)40 (35–45)–40 (35–45, 244)P valuedThere period.<0.01CI, interval.a method.b 5 patients.c One analyzed.d There period.e interval. classification rearrangements revealed that, ones 23 (16–28 32); variants, (25–36 33) 0.05). For insertions), (15–24 44); meanwhile rearrangements, (25–65 19) Figures S1 S2; difference groups (20 vs. 106 295, respectively) 1b; A comparison presence absence (28 55 161, respectively; P 2a). Immunostaining determine 146 Among 64 express α5, 82 did not. group Supplementary S2. Genotype 47 (57.3%) α5-negative contrast, 3 (4.7%) α5-positive lower (29 >50 64, 2b). 207 examined To assess drugs, (n 126) 81) treatments. findings longer (>50 132), 33 interval: 28–73 56). half until 76; 0.05) 4). 75), (9–23 25) (20–43 50; treatment, 0.001) noted S1).Figure 4Renal proportion inhibitor/angiotensin blocker (ACEI/ARB) long dashed double-dotted line (red) indicates ACEIs/ARBs 56); (ESRD) interval [CI]: years) (blue) 76); most solid (black) 50); CI: 9–23 (green) 25); 20–43 Exact values hazard ratios S1.View Image ViewerDownload Hi-res image Download (PPT) study, proven previously observed Western cohorts. replicated improved outcome ARB. first reveal nephroprotective (delay Jais al.6Jais any considerably previous report. This presumably system blockade; 48% (207 participants) received ARB diagnosis. cohort; particular, mild phenotype, deletions/insertions).5Bekheirnia prior intermittent mutations), transcriptional difficulty technique. Recently, produce transcripts; 21) 0.01).8Horinouchi included variants; 32) 3, an 15 S2). 1). important patient's accurate estimation prognosis. already established. al.10Gross exhibit delaying progression randomized controlled trials reduce proteinuria syndrome.17Webb N.J. Lam Shahinfar al.Efficacy safety losartan syndrome—results subgroup prospective, randomized, placebo- amlodipine-controlled trial.Nephrol 2011; 26: 2521-2526Crossref (36) Scholar,18Webb Wells T.G. al.Losartan enalapril comparable reducing 28: 737-743Crossref (26) latest control trial preemptive safe efficient.19Gross Tönshoff Weber L.T. multicenter, placebo-controlled, double-blind phase open-arm efficacy ramipril Alport's 2020; 97: 1275-1286Abstract (23) current additional evidence >22 many clinicians attributed improvement XLAS, clear depending determined. investigate prolonged untreated ACEI/ARB, shorter (12 >17 nontruncating), final worse From results, regarding big their period. although considered great significance individuals' they avoid care adolescence young adulthood. spite substantial ACEI/ARB-treated still expected developed. regard show modifying into seen very promising strategy. investigated factors related Like picture.15Hashimura 42% membrane. high percentage might subject sample bias atypical likely undergo testing. S2, hence, reflects its genotype. Regarding group, exon 51, corresponds noncollagenous domain gene. It will outside domain.5Bekheirnia silent 29; skipping (a 151-bp transcript) leukocyte mRNA. case amount normally led phenotype. detection serve good prognostic marker XLAS. Similarly, own limitations. First all, randomization. cannot exclude cofounders described below. collect information dose timing initiation administration, cumulative administration stratified according constructed solely introduced disease. reports suggest earlier therapeutic intervention lead better failure,10Gross able finding, lack point start collected worsen function poorly hypertension, nonsteroidal anti-inflammatory drug use, incidental disease); thus, analyze impacts factors. conclusion, strongly correlated study. Furthermore, remarkable support facilitate decisions. All procedures reviewed approved Institutional Review Board Kobe University School Medicine. Informed consent parents before participating Patients enrolled referred hospital evaluation analysis, 2006 2018. Most underwent follow-up local hospitals Japan. Based pathologic history, laboratory patients' medical records analysis. defined increased levels protein urine, protein/creatinine ratio >0.2 g/g Cre morning persisted >3 months. undergone ophthalmic evaluations lesions permitted apply audiometry screening students school Japan ages 6, 7, 8, 10, 13, years); system, detected. 514 January 1, 2006, December 31, Of families, 139 diagnosed dominant COL4A3/COL4A4 375 mutations, members. S3). Japanese. symptoms (hematuria/proteinuria/renal failure/pathologic findings) pedigree. Mutational following methods: (i) targeted next-generation sequencing custom panel; (ii) conventional direct Sanger method exons exon-intron boundaries; (iii) multiplex ligation-dependent probe amplification detect copy-number variations; (iv) reverse transcription-polymerase chain reaction (PCR) abnormal splicing. initially (ii); if detected, then proceeded methods (iv). PCR genomic DNA boundaries. Blood samples members; isolated peripheral blood leukocytes QuickGene Mini 80 (Kurabo, Osaka, Japan), accordance manufacturer's instructions. 51 amplified PCR, previously.5Bekheirnia Scholar,6Jais Scholar,15Hashimura PCR-amplified products purified subjected Dye Terminator Sequencing Kit (Amersham Biosciences, Piscataway, NJ) automatic sequencer (model ABI Prism 3130; PerkinElmer, Waltham, MA). panel designed sequences; list provided S3. Next-generation prepared HaloPlex Target Enrichment System (Agilent Technologies, Santa Clara, CA), Amplified target libraries sequenced via MiSeq (Illumina, San Diego, CA) SureCall (v.3.0; Agilent Technologies). Detected sequencing. used data, combined pair software, screen variations genes. Briefly, compare reference variations, described.20Nagano Morisada N. copy diseases.Clin 881-888Crossref (15) Multiplex SALSA P191/192 instructions (MRC-Holland, Amsterdam, Netherlands). 100 ng μl deionized water denatured hybridized overnight mix. Ligation Ligase-65 enzyme, primer Amplification Size Standard 600 mixed thoroughly; mixture later capillary electrophoresis GeneMapper v.3.7 (Thermo Fisher, Total RNA extracted urinary sediment. RNAlater Stabilization Reagent (Qiagen Inc., Valencia, then, reverse-transcribed cDNA random hexamers Superscript III (Invitrogen, Carlsbad, described.15Hashimura nested pairs COL4A5, slight modifications (primer sequences S4).21Inoue Nishio Shirakawa over 90% RT-PCR sequencing.Am Kidney 1999; 34: 854-862Abstract (42) calculations standard statistical software (JMP Windows, version 13; SAS Institute, Cary, NC). occurrence events (renal period) Wilcoxon tests. Meanwhile, Cox proportional hazards model. Associations statistically when 0.05. KI grant Daiichi Sankyo Co., Ltd., consulting fees Takeda Pharmaceutical Company Kyowa Hakko Kirin Ltd. KNo lecture Novartis Pharmaceuticals Corporation. filed patent application antisense nucleotides exon-skipping authors declared competing interests. supported Ministry Health , Labour Welfare Research Intractable Diseases Urinary Tract [H24-nanchitou (nan)-ippan-041 KI] "Research Measures Diseases" Project, Grants-in-Aid Scientific (KAKENHI) Education, Culture, Sports, Science Technology (subject ID: 16K19642 19K17710 TY, 15K09691 KNo, 17H04189 KI), AMED under Grant Number 7930006 KI. thank Ryan Chastain-Gross, PhD, Edanz Group (https://en-author-services.edanzgroup.com) editing draft manuscript. TY KNa concept wrote interpreted TH, CN, NS, YA, SIshik, KNa, YS, RR, SIshim, TN, NM TO analyses. HN, HT, HK, critically read .pdf (.26 MB) Help pdf files File (PDF)