Alport Syndrome

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Practice Essentials

The term Alport syndrome encompasses a group of inherited, heterogeneous disorders involving the basement membranes of the kidney and frequently affecting the cochlea and eye as well. The various forms of the disease include the following:

Signs and symptoms

Renal manifestations

Hypertension is usually detectable by the second decade of life. Edema and nephrotic syndrome are present in 30-40% of young adults with Alport syndrome; they are not common in early childhood, but their incidence progressively increases with age. With onset of renal insufficiency, symptoms of chronic anemia and osteodystrophy may become evident.

Hearing impairment

Sensorineural deafness is a characteristic feature observed frequently, but not universally, in patients with Alport syndrome. About 50% of male patients with XLAS show sensorineural deafness by age 25 years, and about 90% are deaf by age 40 years.

Ocular manifestations

Leiomyomatosis

Diffuse leiomyomatosis of the esophagus and tracheobronchial tree has been reported in some families with Alport syndrome.

Autosomal dominant Alport syndrome

Renal manifestations and deafness in this rare form of Alport syndrome are usually identical to those occurring in patients with XLAS, but renal failure may occur at a later age.

See Clinical Presentation for more detail.

Diagnosis

See Workup for more detail.

Management

Pharmacologic

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) should be administered to patients with Alport syndrome who have proteinuria with or without hypertension. Both classes of drugs apparently help to reduce proteinuria by decreasing intraglomerular pressure. Moreover, by inhibiting angiotensin II, a growth factor that is implicated in glomerular sclerosis, these drugs have a potential role in slowing sclerotic progression.

Surgical

Kidney transplantation is usually offered to patients with Alport syndrome who develop end-stage renal disease (ESRD). Recurrent disease does not occur in the transplanted kidney, and the allograft survival rate in these patients is similar to that in patients with other renal diseases. However, anti – glomerular basement membrane (anti-GBM) nephritis develops in a small percentage of transplant patients with Alport syndrome.

See Treatment and Medication for more detail.

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Electron micrograph of a kidney biopsy from a patient with Alport syndrome. Note the splitting and lamellation of the glomerular basement membrane (se....

Background

The term Alport syndrome refers to a group of inherited, heterogeneous disorders involving the basement membranes of the kidney and frequently affecting the cochlea and eye as well. These disorders are the result of mutations in type IV collagen genes (see the image below). (See Pathophysiology and Etiology.)


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Electron micrograph of a kidney biopsy from a patient with Alport syndrome. Note the splitting and lamellation of the glomerular basement membrane (se....

The mode of inheritance is X-linked in 85% of cases, autosomal recessive in 10-15%, and autosomal dominant in a relatively small percentage of individuals with Alport syndrome. According to whether end-stage renal disease (ESRD) develops before or after age 30 years, X-linked Alport syndrome (XLAS) arbitrarily is categorized as either the juvenile type or the adult type. The juvenile type is encountered in 75% of kindreds. (See Pathophysiology and Etiology and DDx.)

Disease features

In 1927, Alport first described the combination of progressive hereditary nephritis with sensorineural deafness. The presence of the following features suggests the diagnosis of Alport syndrome (See DDx):

The diagnosis of Alport syndrome is confirmed by the presence of splitting or lamellation of the GBM on electron microscopy (see image below) or a pathogenetic mutation in the COL4A5 gene or 2 pathogenic mutations in COL4A3 or COL4A4 genes.[2]

Children with Alport syndrome may initially present with only persistent hematuria and a family history of hematuria. Auditory or ocular manifestations may appear later in life. The typical changes of the GBM are also age dependent and may be absent from initial biopsy samples obtained from young children with Alport syndrome. (See History, Physical Examination, and DDx.)

No specific treatment exists for patients with Alport syndrome, but those who develop ESRD are offered renal transplantation and usually have excellent allograft survival rates. (See Prognosis, Treatment, and Medication.)

Pathophysiology and Etiology

The GBM is a sheetlike structure between the capillary endothelial cells and the visceral epithelial cells of the renal glomerulus. Type IV collagen is the major constituent of the GBM. Each type IV collagen molecule is composed of 3 subunits, called alpha (IV) chains, which are intertwined into a triple helical structure. Two molecules interact at the C-terminal end, and 4 molecules interact at the N-terminal end to form a "chicken wire" network. Six isomers of the alpha (IV) chains exist and are designated alpha-1 (IV) to alpha-6 (IV). The genes coding for the 6 alpha (IV) chains are distributed in pairs on 3 chromosomes (see Table 1, below), as follows[3] :

Table 1. Location and Mutations of the Genes Coding for Alpha (IV) Chains of Type IV Collagen in Alport Syndrome


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Distribution

The alpha-1 (IV) and alpha-2 (IV) chains are ubiquitous in all basement membranes (see Table 2, below), while the other type IV collagen chains have more restricted tissue distribution. The basement membranes of the glomerulus, cochlea, lung, lens capsule, and Bruch and Descemet membranes in the eye contain alpha-3 (IV), alpha-4 (IV), and alpha-5 (IV) chains, in addition to alpha-1 (IV) and alpha-2 (IV) chains. The alpha-6 (IV) chains are present in epidermal basement membranes.

Table 2. Tissue Distribution of Alpha (IV) Chains


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Mutations

Alport syndrome, which is genetically heterogeneous, is caused by defects in the genes encoding alpha-3, alpha-4, or alpha-5 chains of type IV collagen of the basement membranes. The estimated gene frequency ratio of Alport syndrome is 1:5000. The following 3 genetic forms of Alport syndrome exist:

More than 300 mutations have been reported In the COL4A5 genes from families with XLAS. Most COL4A5 mutations are small; these include missense mutations, splice-site mutations, and deletions of less than 10 base pairs.

Approximately 20% of the mutations are major rearrangements at the COL4A5 locus (ie, large- and medium-sized deletions). A particular type of deletion spanning the 5' ends of the COL4A5 and COL4A6 genes is associated with a rare combination of XLAS and diffuse leiomyomatosis of the esophagus, tracheobronchial tree, and female genital tract.

In patients with Alport syndrome, no mutations have been identified solely in the COL4A6 gene. To date, only 6 mutations in the COL4A3 gene and 12 mutations in the COL4A4 gene have been identified in patients with ARAS. Patients are either homozygous or compound heterozygous for their mutations, and their parents are asymptomatic carriers. The mutations include amino acid substitutions, frameshift deletions, missense mutations, in-frame deletions, and splicing mutations. ADAS is rarer than XLAS or ARAS. Recently, a splice site mutation resulting in skipping of exon 21 in the COL4A3 gene was found in ADAS.

Mutation-induced GBM changes

The primary abnormality in patients with Alport syndrome—resulting in aberration of basement membrane—lies in the noncollagenous (NC1) domain of the C-terminal of the alpha-5 (IV) chain in XLAS and that of alpha-3 (IV) or alpha-4 (IV) chains in ARAS and ADAS.

In the early developmental period of the kidney, alpha-1 (IV) and alpha-2 (IV) chains predominate in the GBM. With glomerular maturation, alpha-3 (IV), alpha-4 (IV), and alpha-5 (IV) chains become preponderant through a process called isotype switching. Evidence shows that alpha-3 (IV), alpha-4 (IV), and alpha-5 (IV) chains combine to form a unique collagen network. Abnormality of any of these chains, as observed in patients with Alport syndrome, limits formation of the collagen network and prevents incorporation of the other collagen chains.

Evidence has demonstrated that isoform switching of type IV collagen becomes developmentally arrested in patients with XLAS. This leads to retention of the fetal distribution of alpha-1 (IV) and alpha-2 (IV) isoforms and the absence of alpha-3 (IV), alpha-4 (IV), and alpha-5 (IV) isoforms. The cysteine-rich alpha-3 (IV), alpha-4 (IV), and alpha-5 (IV) chains are thought to enhance the resistance of GBM to proteolytic degradation at the site of glomerular filtration; thus, anomalous persistence of alpha-1 (IV) and alpha-2 (IV) isoforms confers an unexpected increase in the susceptibility of GBM to proteolytic enzymes, leading to basement membrane splitting and damage.

How defective collagen chains result in glomerulosclerosis remains unclear. Evidence now suggests that accumulation of type V and VI collagen chains (along with alpha-1 [IV] and alpha-2 [IV] chains) in the GBM occurs as a compensatory response to the loss of alpha-3 (IV), alpha-4 (IV), and alpha-5 (IV) chains. These proteins spread from a normal subendothelial location and occupy the full width of GBM, altering glomerular homeostasis and resulting in GBM thickening and impairment of macromolecular permselectivity, with subsequent glomerular sclerosis, interstitial fibrosis, and renal failure.

Experimental studies implicate transforming growth factor beta (TGF-beta) and matrix metalloproteinases in the progression of renal disease in Alport syndrome. Further studies are needed to define their precise pathogenetic role and their potential relevance as therapeutic targets.

Hematologic disorders

Several reports describe families with hereditary nephritis associated with deafness, megathrombocytopenia (giant platelets), and, in some families, granulocyte abnormalities. Clinical features include bleeding tendency, macrothrombocytopenia, abnormalities of platelet aggregation (ie, Epstein-Barr syndrome), and, occasionally, neutrophil inclusions that resemble Dohle bodies (ie, May-Hegglin anomaly, Fechtner syndrome).

In most patients, the autosomal dominant pattern of inheritance is observed. In only 2 reports, focal thickening, splitting, or lamellation of the GBM was identified. The basement membrane of these patients showed normal expression of a chain of type IV collagen. So far, the genetic loci involved remain unknown.

Leiomyomatosis

All patients with Alport syndrome diffuse leiomyomatosis complex have been found to have deletions that span the 5' ends of the COL4A5 and COL4A6 genes.

Anti-GBM nephritis

The cause of anti-GBM nephritis is unclear, but about 3-5% of males with Alport syndrome who undergo renal transplantation develop this disorder. These individuals usually have early onset Alport syndrome with clinically significant hearing loss and ESRD by about age 20 years.

Patients who develop anti-GBM nephritis possess circulating anti-GBM antibodies. In persons with ARAS, antibodies predominantly bind to the alpha-3 (IV) and alpha-4 (IV) collagen chains, whereas most antibodies in patients with XLAS bind to the alpha-5 (IV) chain.[4, 5, 6] The antigens recognized by the anti-GBM antibodies are not expressed in the native kidneys of patients with Alport syndrome but are present in the transplanted kidneys.

Recent studies suggest that alpha-5 (IV) collagen forms distinct alpha-345 (IV) and alpha-1256 (IV) networks in the GBM. It has been observed that in patients with posttransplantation anti-GBM nephritis, quaternary epitopes within alpha-345NC1 hexamers may initiate an alloimmune response after transplantation, triggering the formation of anti-GBM antibodies. Reliable detection of alloantibodies by immunoassays using alpha-345NC1 hexamers may facilitate early and accurate diagnosis and improve outcomes.[4]

At present, the only way to determine whether a patient with Alport syndrome will develop posttransplant anti-GBM nephritis is to perform the transplant. Certain patients, however, are at very low risk for developing posttransplant anti-GBM nephritis, including those with normal hearing, patients with late progression to ESRD, and females with XLAS.

Posttransplant anti-GBM nephritis usually develops within the first year of the transplant surgery. Patients typically develop rapidly progressive glomerulonephritis with findings on kidney biopsy showing crescentic glomerulonephritis and linear immune deposits along the GBM. Unlike de novo anti-GBM nephritis, pulmonary hemorrhage is never observed in posttransplant anti-GBM nephritis in patients with Alport syndrome, because the patient's lung tissue does not contain the Goodpasture antigen (NC1 component of the alpha-3 [IV] chain). Treatment with plasmapheresis and cyclophosphamide is usually unsuccessful, and most patients lose the allograft.[7] However, a case of successful treatment with plasmapheresis and intravenous immunoglobulin has recently been reported.[8]

Retransplantation in most patients results in recurrence of anti-GBM nephritis despite the absence of detectable circulating anti-GBM antibodies before transplantation.

Because of excellent graft survival rates and a very low incidence of clinical anti-GBM disease, renal transplantation is not contraindicated in patients with Alport syndrome. However, in patients who have already lost an allograft due to posttransplant anti-GBM nephritis, the optimal management is uncertain because of the high likelihood of recurrence and subsequent allograft loss.

Epidemiology

Occurrence in the United States and internationally

A rare disease, Alport syndrome accounts for approximately 3% of children and 0.2% of adults with ESRD in the United States.[9] In Europe, Alport syndrome accounts for 0.6% of patients with ESRD.

Sex- and age-related demographics

The common X-linked form of Alport syndrome leading to ESRD predominantly affects male individuals.

Hematuria is usually discovered during the first years of life in males with Alport syndrome. If individuals do not have hematuria during the first decade of life, they are unlikely to have Alport syndrome.

Proteinuria is usually absent in childhood, but this condition eventually develops in males with XLAS and in males and females with ARAS.

Hearing loss and ocular abnormalities are never present at birth; they usually become apparent by late childhood or early adolescence, generally before the onset of renal failure.

Prognosis

Progression of renal failure

Renal prognosis in Alport syndrome depends on the kind of mutation causing the condition. The probability of ESRD in people younger than 30 years is significantly higher (90%) in patients with a large rearrangement of the COL4A5 gene than it is in those with minor mutations (50-70%). Furthermore, the rate of progression of renal disease is fairly constant among patients within a particular family but shows significant variability between different families.

XLAS

ESRD develops in virtually all males with XLAS, with the degree of proteinuria in the patient being predictive of the rate of disease progression. Male patients with the typical X-linked disease have a renal half-life of about 25 years, with about 90% of these individuals developing ESRD by age 40 years.[10]

Patients with a family history of juvenile-type Alport syndrome or with early onset deafness and ocular changes typically progress to ESRD by age 20-30 years.

Female patients with XLAS tend to have mild renal disease, with many surviving to old age. However, studies have shown significant renal morbidity in female patients who develop proteinuria and hearing loss.[11, 12] The reported probability of ESRD in female patients is 12% by age 40 years, 30% by age 60 years, and 40% by age 80 years.

Risk factors for progression to ESRD are episodes of gross hematuria in childhood, nephrotic range proteinuria, and diffuse GBM thickening on examination with an electron microscope.

ARAS

The renal prognosis for all patients, male and female, with autosomal recessive disease is poor, with most progressing to ESRD.

Patient Education

Provide pre-ESRD education for patients with Alport syndrome to discuss various options and issues regarding renal replacement therapy (eg, dialysis, transplantation). Arrange dietary counseling for patients approaching ESRD.

Avoid administering nephrotoxins in patients with Alport syndrome, including over-the-counter nonsteroidal analgesic agents.

In asymptomatic patients, stress the importance of yearly physical examinations and laboratory evaluations. Advise patients to receive audiometry and visual testing every 2 years.

Advise parents affected with Alport syndrome and potential carriers of the disorder to obtain genetic counseling.

For patient education information, see Urine and blood Analsis.

History

In any child or adolescent with persistent microscopic hematuria, carefully seek a family history of hematuria, early onset deafness, and renal insufficiency (especially in male patients).[1]

In patients with typical clinical findings for Alport syndrome but a negative family history for the disease, suspect the autosomal recessive form. Occasionally, mild clinical manifestations are observed in carriers (heterozygotes) of autosomal recessive Alport syndrome (ARAS).

Renal manifestations

Hematuria

Gross or microscopic hematuria is the most common and earliest manifestation of Alport syndrome. Microscopic hematuria is observed in all males and in 95% of females. This condition is usually persistent in males, whereas it can be intermittent in females. Like immunoglobulin A (IgA) nephropathy, approximately 60-70% of patients experience episodes of gross hematuria, often precipitated by upper respiratory infection, during the first 2 decades of life. Hematuria is usually discovered during the first years of life in males. If a male patient does not present with hematuria during the first decade of life, he is unlikely to have Alport syndrome.

Proteinuria

Proteinuria is usually absent in childhood but eventually develops in males with X-linked Alport syndrome (XLAS) and in males and females with ARAS. Proteinuria usually progresses with age and can occur in the nephrotic range in as many as 30% of patients. Significant proteinuria is infrequent in females with XLAS, but it may occur.

Hypertension

This condition is usually present in males with XLAS and in males and females with ARAS. Incidence and severity increases with age and degree of renal failure.

Hearing impairment

Sensorineural deafness is a characteristic feature observed frequently, but not universally, in patients with Alport syndrome. Some families with Alport syndrome have severe nephropathy but normal hearing. Hearing loss is never present at birth. Bilateral, high-frequency sensorineural hearing loss usually begins by late childhood or early adolescence, generally before the onset of renal failure. In the early stages of the disease, hearing loss is detectable only by means of audiometry.

As hearing loss progresses, it extends to the low frequencies, including those of human conversation, and patients require hearing aids. Hearing impairment is always associated with renal involvement.

About 50% of male patients with X-linked Alport syndrome show sensorineural deafness by age 25 years, and about 90% are deaf by age 40 years.

Ocular manifestations

Anterior lenticonus

Anterior lenticonus, which occurs in approximately 25% of patients with XLAS, is the pathognomonic feature of Alport syndrome. In this condition, the lens surface protrudes conically into the anterior chamber of the eye because of a thin and fragile basement membrane of the lens capsule. The lenticonus is most marked anteriorly because the capsule is thinnest there, the stresses of accommodation are more marked, and the lens is least supported.

Anterior lenticonus is not present at birth but is manifested by a slowly progressive deterioration of vision, requiring patients to change the prescription of their glasses frequently. The condition is not accompanied by eye pain, redness, or night blindness, and no defect in color vision occurs.

Dot-and-fleck retinopathy

This is the most common ocular manifestation of patients with Alport syndrome, occurring in approximately 85% of males with XLAS. Rarely observed in childhood, it usually becomes apparent at the onset of renal failure. Dot-and-fleck retinopathy is usually asymptomatic, with no associated visual impairment or night blindness.

Posterior polymorphous corneal dystrophy

This condition is rare in Alport syndrome. Most patients are asymptomatic, although some of them may develop slowly progressive visual impairment.

Temporal macular thinning

The L1649R mutation in the COL4A5 gene occasionally causes severe temporal macular thinning, a prominent sign associated with XLAS.[13]

Leiomyomatosis

Diffuse leiomyomatosis of the esophagus and tracheobronchial tree has been reported in some families with Alport syndrome. Symptoms usually appear in late childhood and include dysphagia, postprandial vomiting, substernal or epigastric pain, recurrent bronchitis, dyspnea, cough, and stridor. Leiomyomatosis is confirmed by computed tomography (CT) scanning or magnetic resonance imaging (MRI).

ARAS

ARAS is much less common than XLAS, accounting for 10-15% of all patients with Alport syndrome. ARAS is usually observed in consanguineous marriages. The parents are asymptomatic or mildly affected, while their children (ie, both boys and girls) are often equally and severely affected. The clinical features are usually identical to those observed in patients with XLAS. Renal failure may have an earlier onset. Dot-and-fleck retinopathy and anterior lenticonus also occur in patients with ARAS.

ADAS

This rare form of Alport syndrome is present in successive generations, and males and females are often equally and severely affected. Renal manifestations and deafness are usually identical to those occurring in patients with XLAS, but renal failure may occur at a later age. Clinical features confined to autosomal dominant Alport syndrome (ADAS) include the following:

Physical Examination

The findings on physical examination may initially be unremarkable, but with time, patients develop progressive renal failure manifested by hypertension, edema, and anemia. Moreover, various extrarenal features may also be observed.

Renal manifestations

Clinical renal findings include the following:

Hearing impairment

In the early stages, hearing impairment is detectable only by audiometry, with bilateral hearing loss of high tones in frequencies ranging from 2000-8000 hertz (Hz).

In males with XLAS and in males and females with ARAS, the hearing deficit is progressive and eventually involves lower frequencies, including those of conversational speech.

In females with XLAS, hearing loss occurs less frequently and later in life than it does in males. The risk of developing hearing loss by age 40 years is approximately 90% in males and 10% in females with XLAS. Approximately 60% of patients with ARAS usually develop hearing loss when they are younger than 20 years. In patients with Alport syndrome, studies of brainstem auditory-evoked responses indicate the cochlea as the site of the lesion involved with hearing impairment.

Animal studies reveal marked thickening of the basement membranes of the strial vessels of the cochlea; however, only limited information is available regarding the inner ear histology in humans with Alport syndrome. Striking alterations of the stria vascularis of the cochlea are described.

Ocular manifestations

Anterior lenticonus

As previously mentioned, anterior lenticonus is the pathognomonic feature of patients with Alport syndrome, and its presence in any individual is highly suggestive of the disease. This ocular condition serves as a valuable marker of severity in Alport syndrome and is almost invariably accompanied by progressive renal failure and hearing loss. (Patients with Alport syndrome and anterior lenticonus usually progress to end-stage renal disease (ESRD) and deafness before age 30 years.)

Diagnosis of anterior lenticonus is made by slit lamp examination. Minor degrees of lenticonus are difficult to detect but are suggested by distinctive oil droplet appearance on the red reflex on slit lamp examination.

The diagnosis is confirmed when the central part of the lens projects anteriorly 3-4 mm in an axial projection on biomicroscopic examination. The condition is usually bilateral, causes a slowly progressive axial myopia, and (rarely) may progress to anterior capsular cataract, for which surgical extraction is required.

Ultrastructure analysis of the anterior lens capsule by electron microscopy confirms the diagnosis of Alport syndrome.[14] This condition rarely progresses to spontaneous rupture of the lens capsule, and posterior lenticonus is very uncommon.

Dot-and-fleck retinopathy

This condition is the most common ocular manifestation in patients with Alport syndrome, occurring in approximately 85% of males with XLAS. Dot-and-fleck retinopathy is rarely observed in childhood, instead usually becoming apparent at the onset of renal failure.

Numerous bilateral, white and yellow perimacular dots and flecks occur in this condition. These spare the fovea but can spread to the periphery. No associated visual impairment or night blindness occurs. Typically, dot-and-fleck retinopathy does not fluoresce with angiography.

These dots are thought to be located at the level of the retinal pigment epithelium–Bruch membrane–choriocapillaris complex. The abnormal basement membrane proteins in patients with Alport syndrome may result in enhanced permeability of the Bruch membrane and the underlying choriocapillaris, allowing accumulation of lipofuscin and other undefined substances in the retinal pigment epithelium or in the Bruch membrane.

Posterior polymorphous corneal dystrophy

A rare ocular sign of Alport syndrome, posterior polymorphous corneal dystrophy manifests as clear vesicles alone or in groups (string of pearls) on the endothelial surface of the cornea. This condition is usually bilateral but can be unilateral or asymmetrical. It is attributed to the lamellation and thickening of the outer layer of the Descemet membrane. The occurrence of posterior polymorphous corneal dystrophy in any individual is highly suggestive of Alport syndrome.

Leiomyomatosis

An association of Alport syndrome with diffuse leiomyomatosis of the esophagus and tracheobronchial tree is reported in at least 26 families. These patients have typical X-linked Alport syndrome, usually the juvenile type, with a high incidence of bilateral posterior subcapsular cataracts. Female patients have vulvar and clitoral leiomyomatosis and other findings like those of male patients. Symptoms appear in late childhood and include dysphagia, postprandial vomiting, recurrent bronchitis, dyspnea, cough, and stridor.

Approach Considerations

Laboratory studies

In individuals with Alport syndrome, urinalysis reveals microscopic or gross hematuria. Proteinuria is found in male patients with X-linked Alport syndrome (XLAS) and in people of both sexes with autosomal recessive disease. Hematologic studies demonstrate the extent of renal insufficiency.

Biopsy

Tissue from the kidneys and skin should be examined for ultrastructural abnormalities. Skin biopsy is less invasive than renal biopsy and should be performed first. Kidney biopsy most often provides the diagnosis if it is not established by skin biopsy.

Genetic testing

If the diagnosis of Alport syndrome remains doubtful after skin or kidney biopsy, genetic analysis can be used to make a firm diagnosis and determine the condition’s mode of inheritance.

Audiometry

All children with a history suggestive of Alport syndrome should undergo high-frequency audiometry to confirm the diagnosis (ie, high-frequency sensorineural hearing loss), as well as periodic monitoring.

Ophthalmic evaluation

Ophthalmic examination is important for the early detection and monitoring of anterior lenticonus, as well as perimacular flecks and other eye lesions.

Renal ultrasonography

In the early stages of Alport syndrome, renal ultrasonograms show healthy-sized kidneys; with advancing renal failure, however, the kidneys shrink symmetrically and progressively and become echogenic.

Urine and Blood Analysis

Urinalysis

A urinary dipstick test and a 24-hour urine specimen for protein and creatinine should be performed to detect hematuria and proteinuria. Also, urinary sediment should be analyzed by microscope to detect dysmorphic red blood cells and red blood cell casts.

Whenever possible, the first-degree relatives of a patient with Alport syndrome should also be screened for microscopic hematuria of glomerular origin.

Proteinuria is usually absent in the first few years of life but eventually develops in male patients with X-linked Alport syndrome (XLAS) and in people of both sexes with autosomal recessive disease. The degree of proteinuria usually increases with age and may reach the nephrotic range in 30-40% of young adults with Alport syndrome.

Blood analysis

Blood counts and serum electrolyte, blood urea nitrogen (BUN), and creatinine levels reflect the degree of renal insufficiency in Alport syndrome.

In addition, individuals with nephrotic syndrome may have clinically significant hypoalbuminemia and hypercholesterolemia.

Some patients with the autosomal dominant form of Alport syndrome also have thrombocytopenia, giant platelets, and granulocytic inclusions.

Biopsy

Renal biopsy

Percutaneous renal biopsy is an important part of the diagnostic workup. The test should be performed at a medical center equipped for ultrastructural analysis with electron microscopy. A medical center that has facilities for evaluating collagen chains of the basement membrane by means of immunohistochemistry is also desirable but not required.

Biopsy may be deferred in a patient with a strong family history of biopsy-proven Alport disease who presents with characteristic clinical features.

Skin biopsy

Because the alpha-5 (IV) chain of type IV collagen is also expressed in the epidermis, immunofluorescent examination of a skin biopsy specimen can be used to establish the diagnosis. Approximately 80% of male patients and 60% of female patients with XLAS have no alpha-5 (IV) collagen in epidermal basement membrane, with the interruption of alpha-5 (IV) expression being total in males and segmental in females.

Studies have shown that many individuals with X-linked Alport syndrome also display abnormalities of alpha-2 (IV) collagen expression in the skin.[15] In addition, most individuals with autosomal recessive Alport syndrome do not express alpha-3 (IV), alpha-4 (IV), or alpha-5 (IV) collagens in skin. Healthy individuals and patients with thin-membrane disease have normal expression of alpha-5(IV) in the skin.

Skin biopsy is especially useful if a kidney biopsy poses an excessive risk, such as in patients with end-stage renal disease (ESRD).

Histologic Findings

The absence of alpha-5 (IV) collagen chains in the epidermal basement membrane on skin biopsy is diagnostic of XLAS. In such cases, kidney biopsy is not necessary for diagnosis; however, the absence of alpha-5 (IV) chains in the epidermal basement membrane is observed in only 80% of males with XLAS. Therefore, the presence of alpha-5 (IV) chains in the epidermal basement membrane does not rule out the diagnosis of XLAS; moreover, the alpha-5 (IV) chain is expressed in the epidermal basement membrane in autosomal recessive disease. This indicates that a mutation in the alpha-5 (IV) chain permits its expression in skin but not in the kidney in XLAS and autosomal recessive Alport syndrome (ARAS).

Light microscopy

In early Alport syndrome, light microscopy findings for kidney biopsy specimens may be normal. The findings that occur with disease progression are nonspecific, contributing little toward the diagnosis. They include segmental and focal glomerulosclerosis, tubular atrophy, interstitial fibrosis, and infiltration by lymphocytes and plasma cells with clusters of foam cells of uncertain origin. Findings on standard immunofluorescence studies are usually negative.

Monoclonal antibodies

Monoclonal antibodies directed against alpha-3 (IV), alpha-4 (IV), and alpha-5 (IV) chains of type IV collagen can be used to evaluate the glomerular basement membrane (GBM) for the presence or absence of these chains. Their absence is diagnostic of Alport syndrome and has not been described in any other condition.

In addition, renal expression of alpha-3 (IV), alpha-4 (IV), and alpha-5 (IV) chains can differentiate XLAS and ARAS. In most patients with XLAS, these chains are absent from the GBM and distal TBM. On the other hand, in ARAS, no expression of alpha-3 (IV) and alpha-4 (IV) chains exists, while the alpha-5 (IV) chain is expressed in the GBM and distal tubular basement membrane (TBM). However, normal staining of the GBM for these 3 chains does not rule out the diagnosis of Alport syndrome.

Electron microscopy

Electron microscopy reveals the characteristic lesions of Alport syndrome. The GBM is irregularly thickened, and the central lamina densa is split and splintered into a heterogeneous network of strands, which enclose electron-lucent areas that may contain microgranulations. The epithelial aspect of the capillary wall is irregular, and epithelial foot processes are fused.

Thickening of the GBM is usually diffuse in adults with Alport syndrome, but in young children with the disorder, the thickening is segmental, and thinning of the basement membrane may be observed or even predominate. The degree of thickening increases with the patient's age and the degree of proteinuria. Therefore, a thick and split GBM is specific for Alport syndrome; however, its absence does not exclude the syndrome, especially in young children. (See the images below.)


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Electron micrograph of a kidney biopsy from a patient with Alport syndrome. Note the splitting and lamellation of the glomerular basement membrane (se....


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Electron micrograph from a patient with Alport syndrome revealing the typical splitting and splintering of the glomerular basement membrane (original ....

Genetic Analysis

If the diagnosis of Alport syndrome remains doubtful after skin or kidney biopsy, screening for genetic mutations may be considered; however, the screening for COL4A3, COL4A4, and COL4A5 mutations is expensive, time consuming, extremely difficult, and not widely available. Moreover, the current detection rate of COL4A5 mutations in relatives with Alport syndrome is only about 50%. For now, therefore, genetic analysis should be restricted to prenatal diagnosis or when uncertainty about diagnosis or mode of transmission of Alport syndrome exists.[16, 17] It is also the only means for diagnosing the carrier state in asymptomatic female individuals with a family history of X-linked Alport syndrome.

Approach Considerations

No definite treatment exists for Alport syndrome. Research indicates that angiotensin-converting enzyme (ACE) inhibitors can reduce proteinuria and the progression of renal disease. Thus, the use of ACE inhibitors is reasonable in patients with Alport syndrome who have proteinuria with or without hypertension; the same is true for angiotensin-receptor blockers (ARBs). Both classes of drugs apparently help to reduce proteinuria by decreasing intraglomerular pressure. Moreover, by inhibiting angiotensin II, a growth factor that is implicated in glomerular sclerosis, these drugs have a potential role in slowing sclerotic progression.

Some reports suggest that cyclosporine may reduce proteinuria and stabilize renal functions in patients with Alport syndrome; however, the studies were small and uncontrolled. Moreover, reports suggest that patient response to cyclosporine can vary and that the drug may accelerate the development of interstitial fibrosis due to calcineurin-induced nephrotoxicity.[18]

Renal failure

Begin appropriate replacement therapy as renal failure advances. Therapy includes erythropoietin for chronic anemia, phosphate binders and vitamin D to manage osteodystrophy, alkali to correct acidosis, and antihypertensive therapy to control blood pressure. Hemodialysis or peritoneal dial3ysis does not raise specific problems.

Pregnancy

In women with the more severe form of Alport syndrome, pregnancy may accelerate the progression to end-stage renal disease (ESRD).

Monitoring

Check 24-hour urinary protein, creatinine, and serum chemistry as follows:

Renal Transplantation

Kidney transplantation is usually offered to patients with Alport syndrome who develop ESRD. Recurrent disease does not occur in the transplanted kidney, and the allograft survival rate in these patients is similar to that in patients with other renal diseases.

However, about 3-5% of male patients with transplants develop anti ̶ glomerular basement membrane (anti-GBM) nephritis. These individuals usually have early onset Alport syndrome with clinically significant hearing loss and ESRD by about age 20 years. Female patients with X-linked Alport syndrome (XLAS) and all patients with healthy hearing or late progression to ESRD have a low risk for anti-GBS nephritis.

In view of the excellent graft survival rates and very low incidence of anti-GBM disease, renal transplantation is not contraindicated in patients with Alport syndrome.[19, 20]

Consultations

Consultations with the following clinicians may be necessary:

Medication Summary

Angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) should be administered to patients with Alport syndrome who have proteinuria with or without hypertension. Both classes of drugs apparently help to reduce proteinuria by decreasing intraglomerular pressure. Moreover, by inhibiting angiotensin II, a growth factor that is implicated in glomerular sclerosis, these drugs have a potential role in slowing sclerotic progression.

In a randomized study comparing the long-term use of losartan (an ARB) with that of enalapril (an ACE inhibitor) in the treatment of proteinuria in children with Alport syndrome, Webb et al found both drugs to be effective and well tolerated. The investigators studied protein levels and renal function in 27 children with Alport syndrome, following urinary protein ̶ to-creatinine ratios and estimated glomerular filtration rates for up to 3 years. It was found that initial proteinuria decreases in the losartan patients were maintained over the follow-up period, while the enalapril patients not only maintained initial decreases but experienced additional reductions in proteinuria over the 3 years. The incidence of adverse events was low for both sets of patients.[21]

Some small, uncontrolled studies have indicated that cyclosporine may reduce proteinuria and stabilize renal functions in patients with Alport syndrome. Nonetheless, there is also evidence to suggest that patient response to cyclosporine can vary and that the drug may accelerate the development of interstitial fibrosis.[18]

Enalapril (Vasotec)

Clinical Context:  Enalapril is a competitive inhibitor of ACE. By preventing the conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, it increases levels of plasma renin and reduces aldosterone secretion.

Fosinopril

Clinical Context:  A competitive inhibitor of ACE, fosinopril reduces angiotensin II levels, decreasing aldosterone secretion.

Lisinopril (Zestril, Prinivil)

Clinical Context:  A competitive inhibitor of ACE, lisinopril reduces angiotensin II levels, decreasing aldosterone secretion.

Quinapril (Accupril)

Clinical Context:  A competitive inhibitor of ACE, quinapril reduces angiotensin II levels, decreasing aldosterone secretion.

Class Summary

These agents help to reduce proteinuria by decreasing intraglomerular pressure. Moreover, by inhibiting the conversion of angiotensin I to angiotensin II, a growth factor that is implicated in glomerular sclerosis, these drugs have a potential role in slowing sclerotic progression.

Losartan (Cozaar)

Clinical Context:  Losartan can be used in patients who are unable to tolerate ACE inhibitors. It is a nonpeptide angiotensin II receptor antagonist that blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II. Losartan may induce a more complete inhibition of the renin-angiotensin system than ACE inhibitors do. Unlike ACE inhibitors, it does not affect the response to bradykinin and is less likely to be associated with cough and angioedema.

Candesartan (Atacand)

Clinical Context:  Candesartan can be used in patients who are unable to tolerate ACE inhibitors. It is a nonpeptide angiotensin II receptor antagonist that blocks the vasoconstrictor and aldosterone-secreting effects of angiotensin II. Candesartan may induce a more complete inhibition of the renin-angiotensin system than ACE inhibitors do. Unlike ACE inhibitors, it does not affect the response to bradykinin and is less likely to be associated with cough and angioedema.

Valsartan (Diovan)

Clinical Context:  Valsartan is appropriate for patients unable to tolerate ACE inhibitors. It may induce a more complete inhibition of the RAAS than do ACE inhibitors, it does not affect the response to bradykinin, and it is less likely to be associated with cough and angioedema. Compared with ACE inhibitors (eg, captopril, enalapril), losartan is associated with a lower incidence of drug-induced cough, rash, and taste disturbances.

Class Summary

ARBS help to reduce proteinuria by decreasing intraglomerular pressure. As with ACE inhibitors, these drugs inhibit the production of angiotensin II, giving them a potential role in slowing the progression of glomerular sclerosis. Unlike ACE inhibitors, however, ARBs do not activate bradykinin and are less likely to be associated with cough and angioedema.

Cyclosporine (Neoral, Sandimmune, Gengraf)

Clinical Context:  Cyclosporine is a cyclic polypeptide that suppresses some humoral immunity and, to greater extent, cell-mediated immune reactions.

Class Summary

Cyclosporine may reduce proteinuria and retard the progression of renal disease by inducing afferent arteriolar vasoconstriction, increasing glomerular permselectivity, and inhibiting proinflammatory lymphokines. Efficacy of this treatment in patients was documented only in small series, and further studies are required before this therapy can be recommended on a routine basis. Abstracts suggest that cyclosporine may accelerate the development of interstitial fibrosis.[18, 22] Therefore, such therapy should be approached with caution and close monitoring.

Author

Ramesh Saxena, MD, PhD, Professor, Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center

Disclosure: e-medicine Honoraria authoring review articles

Coauthor(s)

Prasad Devarajan, MD, FAAP, Louise M Williams Endowed Chair in Pediatrics, Professor of Pediatrics and Developmental Biology, Director of Nephrology and Hypertension, Director of Clinical Nephrology Laboratory, CEO of Dialysis Unit, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine

Disclosure: Coinventor on patents submitted for the use of NGAL as a biomarker of kidney injury None None

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Disclosure: Nothing to disclose.

Additional Contributors

Uri S Alon, MD Director of Bone and Mineral Disorders Clinic and Renal Research Laboratory, Children's Mercy Hospital of Kansas City; Professor, Department of Pediatrics, Division of Pediatric Nephrology, University of Missouri-Kansas City School of Medicine

Uri S Alon, MD is a member of the following medical societies: American Federation for Medical Research

Disclosure: Nothing to disclose.

Craig B Langman, MD The Isaac A Abt, MD, Professor of Kidney Diseases, Northwestern University, The Feinberg School of Medicine; Division Head of Kidney Diseases, The Ann and Robert H Lurie Children's Hospital of Chicago

Craig B Langman, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Nephrology, and International Society of Nephrology

Disclosure: NIH Grant/research funds None; Raptor Pharmaceuticals, Inc Grant/research funds None; Alexion Pharmaceuticals, Inc. Grant/research funds None

Eleanor Lederer, MD Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research; American Society of Nephrology Salary ASN Council Position

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Luther Travis, MD Professor Emeritus, Departments of Pediatrics, Nephrology and Diabetes, University of Texas Medical Branch School of Medicine

Luther Travis, MD is a member of the following medical societies: Alpha Omega Alpha, American Federation for Medical Research, International Society of Nephrology, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

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  6. Borza DB. Autoepitopes and alloepitopes of type IV collagen: role in the molecular pathogenesis of anti-GBM antibody glomerulonephritis. Nephron Exp Nephrol. 2007;106(2):e37-43. [View Abstract]
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  8. Armstead S, Hellmark T, Wieslander J, Zhou X, Saxena R, Rajora N. A case of Alport syndrome with post-transplant anti-glomerular basement membrane disease despite negative anti-glomerular basement membrane antibodies by ELISA treated with plasmapheresis and intravenous immunoglobulin. Case Report Transpl. 2013;In press.
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  11. Jais JP, Knebelmann B, Giatras I, De Marchi M, Rizzoni G, Renieri A, et al. X-linked Alport syndrome: natural history and genotype-phenotype correlations in girls and women belonging to 195 families: a "European Community Alport Syndrome Concerted Action" study. J Am Soc Nephrol. Oct 2003;14(10):2603-10. [View Abstract]
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  14. Citirik M, Batman C, Men G, Tuncel M, Zilelioglu O. Electron microscopic examination of the anterior lens capsule in a case of Alport's syndrome. Clin Exp Optom. Sep 2007;90(5):367-70. [View Abstract]
  15. Patey-Mariaud de Serre N, Garfa M, Bessiéres B, Noël LH, Knebelmann B. Collagen alpha5 and alpha2(IV) chain coexpression: analysis of skin biopsies of Alport patients. Kidney Int. Aug 2007;72(4):512-6. [View Abstract]
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Electron micrograph of a kidney biopsy from a patient with Alport syndrome. Note the splitting and lamellation of the glomerular basement membrane (see arrows).

Electron micrograph of a kidney biopsy from a patient with Alport syndrome. Note the splitting and lamellation of the glomerular basement membrane (see arrows).

Electron micrograph of a kidney biopsy from a patient with Alport syndrome. Note the splitting and lamellation of the glomerular basement membrane (see arrows).

Electron micrograph from a patient with Alport syndrome revealing the typical splitting and splintering of the glomerular basement membrane (original magnification X3000). Courtesy of Glen S. Markowitz, MD, Department of Pathology, Columbia University College of Physicians and Surgeons, New York.

Electron micrograph of a kidney biopsy from a patient with Alport syndrome. Note the splitting and lamellation of the glomerular basement membrane (see arrows).

Electron micrograph from a patient with Alport syndrome revealing the typical splitting and splintering of the glomerular basement membrane (original magnification X3000). Courtesy of Glen S. Markowitz, MD, Department of Pathology, Columbia University College of Physicians and Surgeons, New York.

Alpha (IV) Chain Genes Chromosomal Location Mutation
Alpha-1 (IV)COL4A113Unknown
Alpha-2 (IV)COL4A213Unknown
Alpha-3 (IV)COL4A32ARASa
Alpha-4 (IV)COL4A42ARAS
Alpha-5 (IV)COL4A5XXLASb
Alpha-6 (IV)COL4A6XLeiomyomatosisc
a Autosomal recessive Alport syndrome (mutations spanning 5' regions of COL4A5 and COL4A6 genes).

b X-linked Alport syndrome.

c Autosomal recessive Alport syndrome.

Alpha (IV) Chain Tissue Distribution
Alpha-1 (IV)Ubiquitous
Alpha-2 (IV)Ubiquitous
Alpha-3 (IV)GBM, distal TBMa, Descemet membrane, Bruch membrane, anterior lens capsule, lungs, cochlea
Alpha-4 (IV)GBM, distal TBM, Descemet membrane, Bruch membrane, anterior lens capsule, lungs, cochlea
Alpha-5 (IV)GBM, distal TBM, Descemet membrane, Bruch membrane, anterior lens capsule, lungs, cochlea
Alpha-6 (IV)Distal TBM, epidermal basement membrane
a Tubular basement membrane.