Genetics, pathogenesis, and pathology of hereditary nephritis (Alport syndrome) Author Clifford E Kashtan, MD Section Tej K Mattoo, MD,

DCH, Richard J Glassock, MD, MACP Deputy Melanie S Kim, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: May 2013. | This topic last updated: mar 29, 2013.

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INTRODUCTION Hereditary nephritis (or Alport syndrome) is an inherited progressive form of glomerular disease that is often associated with sensorineural hearing loss and ocular abnormalities [1-4]. The prevalence of the disease is estimated at approximately 1 in 50,000 live births [5]. Alport syndrome reportedly accounts for 0.3 to 2.3 percent of new cases of end-stage renal disease (ESRD) [6,7]. The pathogenesis, genetics, and renal pathology of Alport syndrome will be reviewed here. The clinical manifestations and course, diagnosis, and treatment of Alport syndrome are discussed separately. (See "Clinical manifestations, diagnosis and treatment of hereditary nephritis (Alport syndrome)".) PATHOGENESIS Elucidation of the pathogenesis of Alport syndrome was facilitated by the chance observation that the glomerular basement membrane (GBM) of most affected patients did not bind antibodies from patients with anti-GBM antibody disease (including Goodpasture's syndrome) [3,8-10]. This finding suggested an abnormality in type IV collagen, the protein target of anti-GBM antibodies. Subsequent research efforts confirmed that the primary abnormality resides in type IV collagen as discussed in the following section. Genetics Alport syndrome is a primary basement membrane disorder arising from mutations in genes encoding several members of the type IV collagen protein family. Type IV collagen molecules are composed of three alpha chains that form triple-helical structures through specific interactions of C-terminal noncollagenous domains [9]. Six distinct IV collagen chains are encoded by six different genes that are distributed in head-to-head pairs on three chromosomes. The genes include: COL4A1 and COL4A2 at 13q34 COL4A3 and COL4A4 at 2q35-37 COL4A5 and COL4A6 on chromosome X.

The six alpha chains of type IV collagen form three triple helical protomers: alpha-1-1-2, alpha-3-4-5, and alpha-5-5-6. These protomers are further organized into collagen networks by end-to-end connections via Cterminal and N-terminal interactions. Genetic analyses of affected families have identified the affected genes for the three different modes of transmission seen in patients with Alport syndrome as discussed in the following sections. These mutations disrupt the synthesis of type IV collagen and/or the formation of type IV collagen protomers and networks. X-linked inheritance X-linked Alport syndrome accounts for approximately 80 percent of Alport syndrome cases. It arises from mutations in the COL4A5 gene on the X chromosome, which codes for the alpha-5(IV) chain of type IV collagen [2,11-17]. Confirmation of the direct pathogenetic role of these mutations was provided by an animal model in which a specific known human nonsense mutation was introduced into the mouse COL4A5 gene [18]. The primary clinical and pathologic findings of human X-linked disease were recapitulated in this animal model. This mode of inheritance leads to important clinical characteristics in affected families:

Father to son transmission does not occur, since the father passes only the unaffected Y chromosome to his son. Women with X-linked Alport syndrome are heterozygous carriers of the disease mutation. Almost all carriers have some degree of hematuria, and a significant minority develop renal failure [19]. The variable course in women is probably due to lyonization, by which only one X chromosome is active per cell. As a result, in most women with X-linked Alport syndrome, roughly one-half of the cells will express the mutant X gene and the remaining cells the normal COL4A5 gene, leading to a varied phenotype that is generally less severe than in affected males. The influence of X-inactivation on renal outcomes in heterozygotes was recently confirmed in the X-linked Alport syndrome mouse model [20]. (See "Clinical manifestations, diagnosis and treatment of hereditary nephritis (Alport syndrome)", section on 'Carriers'.)

Autosomal recessive inheritance Autosomal recessive inheritance accounts for about 15 percent of patients with Alport syndrome [15]. It arises from genetic defects in either the COL4A3 or COL4A4 genes. The COL4A3 and COL4A4 genes encode the alpha-3(IV) chain (which contains the Goodpasture antigen) and the alpha-4(IV) chain, respectively. Females are as severely affected as males [12,21,22], and the clinical manifestations in both sexes are virtually identical to those of classic X-linked hereditary nephritis in males [21,23]. (See "Clinical manifestations, diagnosis and treatment of hereditary nephritis (Alport syndrome)", section on 'Clinical manifestations and course'.) Autosomal dominant inheritance About 5 percent of patients with Alport syndrome have autosomal dominant disease, which arises from heterozygous mutations in the COL4A3 or COL4A4 genes [24-26]. The clinical and pathologic features of this form are similar to those of X-linked disease, although deterioration of renal function tends to occur more slowly [27]. It is unclear why some heterozygous mutations in the COL4A3 or COL4A4 genes cause autosomal dominant Alport syndrome, a progressive renal disease, while others are associated with thin basement membrane nephropathy, which typically has a benign outcome [25,26,28]. Some evidence suggests that genetic factors other than mutations in these genes may affect underlying clinical features [26]. (See "Thin basement membrane nephropathy (benign familial hematuria)".) Mechanism of glomerular injury The alpha-3, alpha-4, and alpha-5(IV) chains are highly expressed and co-distributed within the normal GBM [29]. They form a type IV collagen network within the GBM that is distinct from that formed by alpha-1(IV) and alpha-2(IV) chains [2,30]. Mutations affecting the alpha-3, alpha4, and alpha-5(IV) chains impair their deposition into this collagen network, leading to secondary changes in GBM composition that predispose to the development of glomerulosclerosis. Several observations support this explanation of the pathophysiologic processes involved in Alport syndrome: In most patients with alpha-5(IV) mutations, the alpha-3, alpha-4 chains, and alpha-5(IV) chains are all absent from the GBM [17]. However, transcription of the alpha-3(IV) and alpha-4(IV) genes is not turned off in the renal cortex, suggesting that failure of incorporation of these chains is responsible for the lack of glomerular expression and not failure of synthesis [31]. The GBM is characterized by the absence of the alpha-3, -4, and -5(IV) chains and by persistence of the fetal distribution of alpha1 and alpha-2(IV) chains [32]. In patients with autosomal recessive Alport syndrome, primary mutations in the alpha-3(IV) chain prevent the expression of the alpha-3, alpha-4, and alpha-5(IV) chains in GBM. This hypothesis is supported by observations in murine and dog models of hereditary nephritis due to deletion of the alpha-3(IV) chain or a nonsense mutation of the alpha-5(IV) chain [32-36]. As an example, in a murine model due to deletion of the alpha-3(IV) chain, abnormalities in the GBM included absence of alpha-4(IV) and alpha-5(IV) collagen chains, the overexpression of alpha-1(IV)

and alpha-2(IV) chains and laminin alpha-5, and markedly elevated levels of fibronectin and perlecan (a heparan sulfate proteoglycan) in the basal laminae [33,35]. Alpha-3, alpha-4, and alpha-5(IV) chain tissue distribution Monoclonal antibody probes have been used to determine the tissue distribution of the alpha-3, alpha-4, and alpha-5(IV) chains in normal tissues and tissues of Alport patients. These chains are normally located in Bowman's capsule and the basement membranes of the glomerulus, distal and collecting tubules, and several basement membranes of the cochlea and eye [37,38]. Thus, an abnormality in any of these chains can impair the integrity of basement membranes in these sites leading to the various clinical findings of Alport syndrome. In normal individuals the alpha-5(IV) chain is present in the basement membrane underlying the epidermis, as a component of alpha-5-5-6 networks. The alpha-3 and alpha-4(IV) chains are normally absent from the basement membrane.

Skin Immunohistochemical studies with a monoclonal antibody directed against the alpha-5(IV) chain demonstrated complete absence of alpha-5(IV) chain within epidermal basement membranes in most males with X-linked Alport syndrome, while female carriers had discontinuous staining (picture 1) [37]. The latter observation is compatible with lyonization in female carriers, in whom it would be expected that one-half of their cells would express a normal alpha-5(IV) chain. However, conventional fluorescence microscopy will detect alpha-5(IV) chain of the skin in about 20 percent of males with X-linked Alport syndrome and 30 to 40 percent of heterozygous females. Confocal laser scanning microscopy (CLSM) has demonstrated either a decrease in expression or an abnormal interrupted distribution of alpha-5(IV) compared to alpha-2(IV) chain staining in some but not all of these patients [39,40]. Although this technique is currently primarily a research tool, these findings suggest that CLSM may play a future role in the diagnosis of Alport syndrome, as it appears to be a more sensitive diagnostic modality than conventional fluorescence microscopy. All patients with autosomal recessive and autosomal dominant Alport syndrome have normal skin reactivity for alpha-5(IV) (picture 1). Thus, the presence of epidermal basement membrane staining for the alpha-5(IV) does not exclude a diagnosis of X-linked or autosomal Alport syndrome. However, the absence of alpha5(IV) chain in a skin biopsy is diagnostic of disease. Kidney Immunostaining of renal biopsy specimens for type IV collagen is useful in the evaluation of patients with suspected Alport syndrome (figure 1). X-linked disease As noted previously, males with X-linked Alport syndrome typically show complete absence of immunostaining for the alpha-3, alpha-4, and alpha-5(IV) chains in their kidneys, while heterozygous females exhibit patchy loss of staining in GBM and tubular basement membranes. (See 'Mechanism of glomerular injury' above.) As with skin staining for the alpha-5(IV) chain, approximately 20 percent of males with X-linked Alport syndrome have normal staining of renal basement membranes for the alpha-3, alpha-4, and alpha-5(IV) chains. Further quantitative analysis reveals lower amounts of the alpha-3, alpha4, and/or alpha-5(IV) chains in these cases compared to normals [41]. Some of these patients have missense mutations of COL4A5, which may explain the detection of alpha IV chains with immunostaining, albeit a decrease in intensity [42]. Autosomal recessive disease Patients with autosomal recessive Alport syndrome have abnormalities of renal type IV collagen expression that differ from those of patients with X-linked disease. These patients typically exhibit complete absence of staining for the alpha-3 and alpha4(IV) chains. However, while their GBM show no staining for the alpha-5(IV) chain, there is staining of Bowman's capsules and tubular basement membranes for the alpha-5(IV) chain. This observation can be interpreted as failure of the alpha-5(IV) chain to be deposited in the GBM due to the absence

of the alpha-3 and alpha-4(IV) chains, but the alpha-5(IV) chain, in conjunction with the alpha-6(IV) chain, is deposited in the basement membranes of the tubule, Bowman's capsules, and epidermis. Lens Anterior lenticonus, which is associated with thinning of the lens capsule, the basement membrane that surrounds the lens, occurs in 20 to 30 percent of males with X-linked Alport syndrome. If present, anterior lenticonus is pathognomonic for Alport syndrome. The lens capsule normally contains alpha-3, alpha-4, and alpha-5(IV) chains. In some patients with anterior lenticonus, these chains are absent from the lens capsule [43]. Cochlea Hearing loss in Alport syndrome may reflect impaired adhesion of the Organ of Corti, which contains the auditory sensory cells, to the basilar membrane of the inner ear. This impaired adhesion is thought to be due to the absence of the alpha-3-4-5 type IV collagen network from the Organ of Corti basement membrane [44]. Other pathologic findings Leiomyomas Leiomyomas are benign tumors characterized by visceral smooth muscle overgrowth within the respiratory, gastrointestinal, and female reproductive tracts. Rarely, X-linked Alport syndrome is associated with leiomyomas. Affected patients carry deletions that involve COL4A5 and extend into the second intron of the adjacent COL4A6 gene [45]. Of note, defects in the alpha-6 chain gene alone do not appear to cause Alport syndrome [2]. The pathogenetic relationship between deletions of the 5' end of the COL4A6 gene and the formation of leiomyomas is not understood. One hypothesis suggests that deletions that encompass both the COL4A5 and COL4A6 genes cause misregulation of neighboring genes, which contribute to smooth muscle overgrowth [45]. RENAL PATHOLOGY Histologic changes in Alport kidneys increase in severity with age. The changes on light microscopy are nonspecific and include focal increases in glomerular cellularity progressing to glomerulosclerosis over time, and an interstitial infiltrate containing lipid-laden foam cells of uncertain origin. The earliest ultrastructural lesion is thinning of the GBM [2,46]. This finding is not pathognomonic since it also occurs in thin basement membrane nephropathy. However, with time, there is development of longitudinal splitting of the lamina densa of the GBM producing a laminated appearance that is diagnostic of Alport syndrome (picture 2A-B). In males with X-linked Alport syndrome, the proportion of GBM showing splitting increases from about 30 percent by age 10 to more than 90 percent by age 30 [46]. (See"Thin basement membrane nephropathy (benign familial hematuria)".) Renal biopsy of affected individuals at a young age may manifest only non-specific light microscopic changes and no definitive electron microscopic findings. However, results of immunostaining for type IV collagen alpha chains is frequently diagnostic even in the absence of specific ultrastructural changes. In prepubertal children, less invasive skin biopsy with appropriate immunohistochemical analysis may be the preferred diagnostic study. (See "Clinical manifestations, diagnosis and treatment of hereditary nephritis (Alport syndrome)", section on 'Diagnosis' and 'Skin' above.) SUMMARY Hereditary nephritis (or Alport syndrome) is a progressive inherited form of glomerular disease that is often associated with neural hearing loss and ocular abnormalities. Alport syndrome is a primary basement membrane disorder arising from mutations in genes encoding several members of the type IV collagen protein family. Alport syndrome is a genetically heterogeneous disease with X-linked, autosomal recessive, and autosomal dominant variants. (See 'Genetics' above.) X-linked variant accounts for approximately 80 percent of affected patients. It arises from mutations in the COL4A5 gene on the X chromosome, which encodes alpha-5(IV) chains. (See 'X-linked inheritance' above.)

Autosomal recessive variant accounts for about 15 percent of patients with Alport syndrome. It arises from genetic defects in either the COL4A3 and COL4A4 genes, which encodes the alpha-3 and alpha-4(IV) chains, respectively. The clinical manifestations of affected patients regardless of gender are the same as male patients with X-linked Alport syndrome. (See 'Autosomal recessive inheritance' above and "Clinical manifestations, diagnosis and treatment of hereditary nephritis (Alport syndrome)".) Autosomal dominant disease accounts for 5 percent of patients with Alport syndrome. It arises from heterozygous mutations in the COL4A3 or COL4A4 genes. The clinical and pathologic features of this variant of Alport syndrome are similar to those of X-linked disease, although deterioration of renal function tends to occur more slowly. (See 'Autosomal dominant inheritance' above.)

The alpha-3, alpha-4, and alpha-5(IV) chains are normally located in Bowman's capsule, and the basement membranes of the glomerulus, distal and collecting tubules, cochlea, and eye. Thus, an abnormality in any of these chains can impair the integrity of basement membranes in these sites, leading to the various clinical findings of Alport syndrome. (See "Clinical manifestations, diagnosis and treatment of hereditary nephritis (Alport syndrome)", section on 'Clinical manifestations and course' and'Mechanism of glomerular injury' above and 'Alpha-3, alpha-4, and alpha-5(IV) chain tissue distribution' above.) In patients with Alport syndrome, renal histologic changes progress with age. The earliest finding is thinning of the GBM. This finding is not pathognomonic since it also occurs in thin basement membrane nephropathy. With increasing age, longitudinal splitting of the lamina densa of the GBM produces a laminated appearance that is diagnostic of Alport syndrome and is present in 90 percent of male patients by 30 years of age (picture 2A-B). (See 'Renal pathology' above.) Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES Clinical manifestations, diagnosis and treatment of hereditary nephritis (Alport syndrome) Author Clifford E Kashtan, MD Section Tej K Mattoo, MD, DCH, Richard J Glassock, MD, MACP Deputy Melanie S Kim, MD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: May 2013. | This topic last updated: apr 12, 2013. INTRODUCTION Hereditary nephritis (or Alport syndrome) is an inherited progressive form of glomerular disease that is often associated with sensorineural hearing loss and ocular abnormalities [1-4]. Alport syndrome is a primary basement membrane disorder arising from mutations in genes encoding several members of the type IV collagen protein family. The clinical manifestations, diagnosis, and treatment of Alport syndrome will be reviewed here. The pathogenesis, genetics, and pathology of Alport syndrome are discussed separately. (See "Genetics, pathogenesis, and pathology of hereditary nephritis (Alport syndrome)".) GENETICS Alport syndrome is a genetically heterogeneous disease that results from mutations in genes encoding the alpha-3, alpha-4, and alpha-5 chains of type IV collagen. These alpha IV collagen chains are normally located in various basement membranes of the kidney, cochlea, and eye. Abnormalities in these chains result in defective basement membranes at these sites, leading to the clinical features of this disorder (ie, progressive glomerular disease, sensorineural hearing loss, and ocular abnormalities). (See "Genetics, pathogenesis, and pathology of hereditary nephritis (Alport syndrome)", section on 'Genetics' and 'Clinical manifestations and course' below.)

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Transmission of Alport syndrome can be X-linked, autosomal recessive, or autosomal dominant. (See "Genetics, pathogenesis, and pathology of hereditary nephritis (Alport syndrome)", section on 'Genetics'.) X-linked transmission accounts for approximately 80 percent of affected patients and arises from mutations in the COL4A5 gene on the X chromosome. Autosomal recessive variant accounts for about 15 percent of patients with Alport syndrome and arises from genetic defects in either the COL4A3 or COL4A4 genes. Autosomal dominant disease accounts for 5 percent of patients with Alport syndrome and arises from heterozygous mutations in the COL4A3 or COL4A4 genes.

INCIDENCE Alport syndrome has been reported in hundreds of unrelated kindreds that represent all geographic and ethnic groups. Although the overall incidence in the general population is unknown, data from the United States demonstrates Alport syndrome accounts for 3 percent of children with end-stage renal disease (ESRD) and 0.2 percent of adults with ESRD [1]. Case series of patients undergoing kidney biopsies demonstrate that the difficulty in determining the incidence as the diagnosis of Alport syndrome varies from 1 to 11 percent depending upon the indications for biopsy [1,5-7]. The gene frequency of Alport syndrome in the United States has been estimated at 1:5000 to 10,000, suggesting there are approximately 30,000 to 60,000 affected individuals in the US [8]. CLINICAL MANIFESTATIONS AND COURSE The classical presentation of Alport syndrome is based upon clinical manifestations of affected males with X-linked disease. These features include glomerular disease that progresses to end-stage renal disease (ESRD), ocular abnormalities (eg, anterior lenticonus), sensorineural hearing loss, and a family history of hematuria associated with renal failure and deafness. Clinical presentation and course in patients with autosomal recessive disease are similar to those with Xlinked disease. Patients with autosomal dominant disease generally exhibit more gradual loss of renal function [9,10]. (See 'Genetics' above.) Renal manifestations The initial renal manifestation of Alport syndrome is asymptomatic persistent microscopic hematuria, which is present in early childhood in affected patients. Since screening urinalysis is seldom performed in routine pediatric primary care, microscopic hematuria may not be detected unless the patient is screened because of an affected family member. Recurrent episodes of gross hematuria are not uncommon especially during childhood. Gross hematuria may be the initial presenting finding and often occurs after an upper respiratory infection [11]. Boys without hematuria by the age of 10 years are unlikely to have Alport syndrome [1]. In early childhood, the serum creatinine and blood pressure are normal. Over time, proteinuria, hypertension, and progressive renal insufficiency develop. ESRD usually occurs between the ages of 16 and 35 years in patients with X-linked or autosomal recessive disease. In some families, the course is more indolent with renal failure being delayed until age 45 to 60, especially in those with autosomal dominant Alport syndrome. In females with X-linked Alport syndrome, recurrent episodes of gross hematuria, proteinuria, hearing loss, and diffuse glomerular basement membrane (GBM) thickening are associated with more severe renal dysfunction and ESRD at an earlier age [12]. Phenotype-genotype correlation The tempo of progressive renal dysfunction depends, at least in part, upon the underlying mutation. Patients with large deletions and nonsense mutations have more severe disease (both renal and extrarenal) than those with missense mutations [1-4,13]. This was illustrated in the following reviews of families with X-linked Alport syndrome that demonstrated the correlation between ESRD and types of mutation in the COL4A5(IV) gene.

In the first study of 195 European families, the risk of ESRD by 30 years of age for patients with missense mutations, splice site mutations, and large deletion, nonsense, or frameshift mutations was 50, 70, and 90 percent, respectively [13]. Large rearrangements of the COL4A5 gene or any mutations that shift the reading frame of the gene were also associated with early onset of hearing loss and a higher incidence of anterior lenticonus [13]. In the second study of 175 families from the United States, the average age of onset for ESRD for patients with missense mutations, splice site mutations, and truncating mutations was 37, 28, and 25 years of age, respectively [14]. Mutations located closer to the 5' end of the gene were associated with a younger onset of ESRD, and an increased risk of ocular changes and hearing loss than those located closer to the 3' end. Patients with splice or truncating mutations were also more likely to have ocular abnormalities and hearing loss.

Hearing loss Bilateral sensorineural hearing loss is a common feature in patients with Alport syndrome [15]. Hearing loss begins in the high frequency range and progresses over time to frequencies in the range of conversational speech. One study of families with X-linked disease reported that audiologic testing detected hearing loss in 85 percent of affected boys and 18 percent of female carriers by 15 years of age [11]. In general, the rate of hearing loss is similar to the progression of renal insufficiency. Ocular manifestations Several ocular defects involving the lens, retina, and cornea have been reported in patients with Alport syndrome [16,17]. Lens Anterior lenticonus is a regular conical protrusion on the anterior aspect of the lens due to thinning of the lens capsule. It occurs in 20 to 30 percent of males with X-linked Alport syndrome and is pathognomonic of the disease. Lenticonus can be complicated by the presence of subcapsular cataracts, which may lead to loss of visual acuity. (See "Cataract in children".) Retina Retinal changes are asymptomatic, and when there is anterior lenticonus, they are always present [18]. The changes consist of bilateral white or yellow granulations that are superficially located in the retina surrounding the foveal area [19]. These findings are also specific for Alport syndrome. Cornea Corneal changes are nonspecific findings in patients with Alport syndrome and include posterior polymorphous dystrophy and recurrent corneal erosion, which can cause severe ocular pain.

Carriers Women with X-linked Alport syndrome are heterozygous carriers of the disease mutation. They have a range of clinical findings due to lyonization, by which only one X chromosome is active per cell. As a result, approximately one-half of their cells will express the mutant COL4A5 gene and the remaining cells the normal COL4A5 gene, leading to a variable phenotype that is generally less severe than in affected males. This was shown in a study of the natural history of female carriers with proven COL4A5 mutations [20]. Among female carriers followed in 195 affected families, the incidence of ESRD before age 40 was only 12 percent, compared with 90 percent in affected males [13]. With increasing age, there was an increased risk of progressive renal disease with a 30 percent probability of developing ESRD by age 60 in these female carriers. However, this may be an overestimate, since approximately one-third of the women, most likely less severely affected, were lost to follow-up. There was variation in phenotypes among family members with the same genotype, most likely due to the variability of gene expression due to lyonization. Risk factors for chronic renal insufficiency in female carriers include episodic gross hematuria in childhood, sensorineural deafness, proteinuria, and the presence of the characteristic lamellation of the basement membrane (GBM) associated with Alport syndrome on renal biopsy [20-22]. By comparison, female carriers with only asymptomatic hematuria by the age of 30 to 40 years have a very small risk of developing ESRD. Leiomyomatosis Leiomyomas are benign tumors characterized by visceral smooth muscle overgrowth within the respiratory, gastrointestinal, and female reproductive tracts. They are found in 2 to 5 percent of

patients and carriers of X-linked Alport syndrome who have chromosomal microdeletion at the 5' ends of COL4A, which extend into the adjacent COL4A6 gene [23,24]. Arterial disease Aneurysms of the thoracic and abdominal aorta have been reported in relatively young male patients, as well as a single case of intracranial aneurysm [25-27]. Other A contiguous gene syndrome consisting of X-linked Alport syndrome, midface hypoplasia, and mental retardation resulting from chromosomal microdeletion involving the COL4A5 gene and adjacent genes has been described [28]. DIAGNOSIS Although the diagnosis of Alport syndrome is generally suspected from the family history of renal failure and deafness [29], the diagnosis is usually confirmed by a skin or renal biopsy. Renal and skin biopsy In a renal biopsy specimen, the characteristic finding of longitudinal splitting of the lamina densa of the glomerular basement membrane (GBM) detected by electron microscopy is diagnostic for Alport syndrome (picture 1A-B). However, in young patients, this characteristic appearance of a laminated GBM may not be present. In males with X-linked Alport syndrome, for example, the proportion of GBM showing splitting increases from about 30 percent by age 10 to more than 90 percent by age 30 [30]. (See "Genetics, pathogenesis, and pathology of hereditary nephritis (Alport syndrome)", section on 'Renal pathology'.) If immunostaining of type IV collagen is used and demonstrates absence or an abnormal distribution of the alpha-3, alpha-4 and/or alpha-5(IV) chains of the GBM, the diagnosis can be made in a child with a family history of renal failure and deafness without the ultrastructural finding of a laminated GBM (figure 1). For example, immunostaining demonstrates absence of staining of the alpha-3, alpha-4, and alpha-5 (IV) chains in the glomerular basement membrane in two-thirds of male patients and discontinuous distribution in female carriers. In addition, there is no staining of alpha-5 (IV) chain in the distal tubular membrane of patients. (See "Genetics, pathogenesis, and pathology of hereditary nephritis (Alport syndrome)", section on 'Alpha-3, alpha-4, and alpha-5(IV) chain tissue distribution'.) A less invasive potential method to diagnose a child with suspected X-linked Alport syndrome is a skin biopsy using commercially available monoclonal antibody against the alpha-5(IV) chain (picture 2) [1,31-35]. If the protein is clearly absent in a suspected male (or is clearly mosaic in a female), a diagnosis of Alport syndrome (or a genetic carrier) can be made without further testing. If the test demonstrates expression of the alpha-5(IV) chain, then the patient has one of the following: A mutation in the COL4A5 gene that permits deposition of a functionally abnormal but antigenically normal alpha-5(IV) chain, which occurs in about 30 percent of male patients with X-linked disease. Autosomal recessive Alport syndrome with abnormalities in either the COL4A3 or COL4A4 gene. Another disorder.

In these uncertain cases, the diagnosis of Alport syndrome can subsequently be confirmed or excluded by a renal biopsy with analysis of type IV collagen expression in the kidney. A renal biopsy should also be performed if results of a skin biopsy are equivocal and a diagnosis is required because of signs of possible progressive renal disease, such as hypertension, proteinuria, or an elevated plasma creatinine concentration. (See "Genetics, pathogenesis, and pathology of hereditary nephritis (Alport syndrome)", section on 'Skin'.) In up to 15 percent of cases, there is no identified family history of renal disease [2] and the diagnosis is made by the presence of the characteristic finding of lamination of the GBM in samples from a renal biopsy. These cases represent new mutations in the COL4A3, COL4A4, or COL4A5 genes [36]. Molecular genetic testing Molecular genetic testing may eventually become the diagnostic procedure of choice because it is noninvasive and can be extremely accurate [37,38]. Since the rate of progression of renal disease may be dependent upon the underlying specific mutation, molecular analysis may eventually provide more prognostic data than either renal or skin biopsy.

The large size and high GC content of the COL4A5 gene render direct mutational analysis of genomic DNA technically difficult. In addition, the analysis of genomic DNA may not detect large gene rearrangements or splice site mutations [39,40]. By comparison, direct mutational analysis of coding sequence (ie, mRNA), rather than genomic DNA, may provide a less laborious and more sensitive method for the detection of splice site mutations [40-43]. Since COL4A5 mRNA is expressed in the skin and hair roots, analysis of cells from these sites may allow a relatively noninvasive diagnostic test [40,44,45]. Appropriate settings in which genetic testing may be beneficial include the following [35]: Prenatal diagnosis. Confirmation or exclusion of the disorder in patients who cannot be unequivocally diagnosed by biopsy. Absolute exclusion of the carrier state in an asymptomatic female. When X-linked and autosomal recessive disease cannot be differentiated by pedigree and immunohistochemical analysis.

Current information on molecular testing for Alport syndrome can be obtained at www.genereviews.org. (Accessed March 17, 2008). DIFFERENTIAL DIAGNOSIS Alport syndrome is typically differentiated from other major causes of persistent glomerular hematuria by a positive family history of hematuria associated with renal failure and deafness. Other glomerular disorders that present in children with microscopic hematuria include IgA nephropathy, in which the family history is usually negative; and thin basement membrane nephropathy, in which the family history may be positive for hematuria but renal failure and deafness are absent. The diagnosis of Alport syndrome is confirmed by skin or renal biopsy. Alport syndrome is distinguished by the presence of the characteristic finding of lamination of the glomerular basement membrane (GBM) in samples from a renal biopsy or absence of type IV collagen by immunostaining. (See "Thin basement membrane nephropathy (benign familial hematuria)" and 'Diagnosis' above and "Glomerular hematuria: IgA; Alport; thin basement membrane nephropathy".) Megathrombocytopenia (thrombocytopenia with large or giant platelets) has been described in some families with autosomal dominant hereditary nephritis and sensorineural deafness. This complex has been referred to as Epstein syndrome or Fechtner syndrome when associated with leukocyte cytoplasmic inclusions. These disorders have been mapped to chromosome 22, and result from mutations in the gene encoding nonmuscle myosin heavy chain 9 (MYH9). Mutations in this gene can also cause Sebastian syndrome, another giant platelet disorder, and nonsyndromic hereditary deafness. These disorders are discussed separately. (See "Causes of thrombocytopenia in children", section on 'Giant platelet disorders'.) Thus, Epstein and Fechtner syndromes represent distinct disorders arising from mutations in noncollagen genes, not variants of autosomal dominant Alport syndrome. In some patients, ultrastructural changes reminiscent of Alport syndrome may be present. However, immunostaining for type IV collagen is normal in patients with Epstein or Fechtner syndrome. MANAGEMENT In patients who develop end-stage renal disease, transplantation is the preferred modality for renal replacement therapy in our practice. There is no specific treatment for Alport syndrome currently available. The use of angiotensin antagonists or cyclosporine has been described in uncontrolled studies on human patients. Angiotensin blockade Several studies have demonstrated that angiotensin blockade therapy reduces proteinuria and diminishes the rate of glomerulosclerosis and disease progression in patients with Alport syndrome [46-50]:

In a 12-week clinical trial of 30 children with Alport syndrome, losartan (angiotensin receptor blockers) reduced proteinuria to a greater extent than placebo oramlodipine [49]. In a cohort of patients followed by the European Alport Registry for a mean duration of over 20 years, retrospective analysis found that initiation of angiotensin-converting enzyme inhibitors delayed dialysis in patients with proteinuria and normal renal function compared with those who never received such therapy or who received treatment only when they developed impaired renal function (dialysis initiated at a mean age of 40, 22, and 25 years, respectively) [50].

Studies of animal models of Alport syndrome have also demonstrated that animals treated with ACE inhibitors compared with controls had a slower decline in renal function, slower increase in proteinuria, and less renal damage (eg, reduced renal fibrosis) [51,52]. Based on these results, angiotensin blockade with an ACE inhibitor (eg, enalapril, lisinopril, ramipril) or an angiotensin receptor blocker (ARB; eg, losartan) is recommended in patients with Alport syndrome and overt proteinuria. It is also reasonable to consider angiotensin blockade therapy in those patients who have microalbuminuria, but who have not yet developed overt proteinuria. (See "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults" and "Treatment of hypertension in children and adolescents", section on 'ACE inhibitors/ARBs'.) Cyclosporine In a canine model of X-linked Alport syndrome, cyclosporine treatment failed to diminish proteinuria, but resulted in longer renal survival [53]. In humans, uncontrolled studies of cyclosporine therapy have produced divergent results. In a Spanish study of eight patients who ranged in age from 15 to 27 years of age at follow-up, serum creatinine values remained stable compared with pretreatment measurements after a mean duration of cyclosporine therapy of 8.4 years [54]. In addition, patients had either a lower or equivalent degree of proteinuria compared with baseline values. In contrast, a study of nine French patients reported that cyclosporine therapy suppressed proteinuria, but reduced glomerular filtration rate and possibly accelerated renal fibrosis [55]. In an uncontrolled study of Italian children with Alport syndrome, cyclosporine therapy transiently reduced proteinuria, but did not prevent subsequent decline in renal function [56]. As there is the potential for nephrotoxicity, until further data demonstrate benefit from cyclosporine therapy, we do not suggest that this agent be used in patients with Alport syndrome to slow the progression of renal disease. Renal transplantation Patients with Alport syndrome typically have excellent renal transplant outcomes. Recurrent disease does not occur in the transplanted graft because the donor kidney has a normal glomerular basement membrane (GBM). However, anti-glomerular basement membrane antibody disease (anti-GBM antibody disease) occurs in approximately 3 percent of affected males who receive transplants. Anti-GBM antibody disease De novo anti-GBM antibody disease develops in approximately 3 percent of transplanted males [2,18,31,57-63]. In males with X-linked disease, antibodies are directed primarily against the alpha-5(IV) chain, but antibodies against the alpha-3(IV) chain are also found in some patients [4,57,60,63-65]. In patients with autosomal recessive Alport syndrome who develop posttransplant anti-GBM disease, the predominant target of anti-GBM antibodies is the alpha-3(IV) chain [65,66]. The vast majority of cases of posttransplant anti-GBM disease in Alport syndrome occur in males. This is consistent with the hypothesis that even a female heterozygote who developed end-stage renal disease would have some cells synthesizing and secreting a normal alpha-5(IV) chain, thus a transplanted kidney would not be expressing a new antigenic epitope to these patients. However, posttransplant anti-GBM disease has been described in females with autosomal recessive disease [66,67]. In these patients, the antiGBM antibodies are directed primarily against the alpha-3(IV) chain. Although anti-GBM antibody disease usually occurs in the first year after transplantation, an interval of several years between transplantation and presentation with anti-GBM disease can occur [31]. Affected

patients typically have circulating anti-GBM antibodies and up to three-quarters of patients may develop crescentic glomerulonephritis and loss of the graft [31,58,59]. The key to early diagnosis of posttransplant anti-GBM antibody disease is a low threshold for obtaining an allograft biopsy with indirect immunofluorescence, which demonstrates the characteristic finding of linear deposition of IgG along the glomerular capillaries and occasionally the distal tubules. The clinician should not rely solely on commercial anti-GBM assays because they are optimized for detection of antibodies directed against the Goodpasture antigen rather than antibodies against the alpha5 IV chain. (See "Pathogenesis and diagnosis of anti-GBM antibody (Goodpasture's) disease", section on 'Diagnosis'.) Plasmapheresis and cyclophosphamide, which are initially used in treating primary anti-GBM disease, appear to be of limited benefit in posttransplant disease [31]. Retransplantation in these patients is associated with a high risk of recurrence (seven of eight in one report) [31]. (See "Treatment of anti-GBM antibody (Goodpasture's) disease".) Because the incidence of clinical anti-GBM antibody disease is low, renal transplantation is not contraindicated in patients with Alport syndrome [42]. However, the optimal management is uncertain in patients who lost their first graft to anti-GBM antibody disease. The recurrence rate is high in subsequent transplants [43,64], but isolated cases of successful retransplantation have been reported [58]. It is unclear why only some patients develop anti-GBM antibody disease after transplantation. In patients with X-linked disease, the specific type of mutation may be an important factor in developing anti-GBM antibody disease. The risk appears to be greatest in patients with COL4A5 mutations that prevent synthesis of the alpha-5(IV) chain [59,61,64]. This was illustrated in one review of Alport patients with posttransplant anti-GBM disease that reported 54 percent (7 of 13) of patients with anti-GBM disease had large deletions in the COL4A5 gene compared with a deletion frequency of 16 percent in all patients with Alport syndrome [61]. However, a COL4A5 gene deletion alone does not appear to be sufficient to cause anti-GBM disease following renal transplantation. In one study, only one of seven patients with a COL4A5 deletion and complete absence of the alpha-5(IV) chain developed anti-GBM disease in the renal transplant [4], suggesting that factors other than exposure to a previously unseen antigen must be involved. The complex interplay between the host's underlying gene defect, immune response factors such as antigen presentation, and immunosuppression are all factors that must be considered in the development of posttransplant antiGBM disease [68]. Differences in the ability to activate the cellular arm of the immune system may be another reason why only some patients develop posttransplant anti-GBM disease. One study evaluated the variation in anti-GBM antibody formation in patients with Alport syndrome in whom posttransplant disease had or had not developed (12 and 10 patients, respectively) [41]. All patients in both groups displayed some combination of antibodies directed against the alpha 3, 4, or 5 chains of type IV collagen, and the pattern of antibody expression did not differ between the two groups. It has also been noted that some Alport patients develop linear IgG staining of the transplant GBM, without concomitant evidence of C3 deposition, glomerulonephritis, or allograft dysfunction [58]. These data suggest that nonhumoral immune factors contribute to the variation in the frequency of anti-GBM disease posttransplant. Living-related donors Since Alport syndrome is a familial disorder, potential living-related kidney donors for Alport patients must be carefully evaluated. Male relatives who do not have hematuria are suitable candidates. Women who are heterozygous for X-linked Alport syndrome are less desirable candidates, with some exceptions [69-71]. Our approach Our management approach is consistent with the clinical practice recommendations for the treatment of Alport syndrome from the Alport Syndrome Research Collaborative [72]. It consists of the following: Annual monitoring for microalbuminuria and proteinuria as soon as the diagnosis of Alport syndrome is made or beginning at one year of age for at-risk children.

Angiotensin blockade therapy is initiated when patients develop overt proteinuria defined as a urinary protein-creatinine ratio (Uprot/Ucr) >0.2 mg/mg or urinary protein excretion greater than 2 4 mg/m per hour in a timed collection. The targeted therapeutic goal of urinary protein-creatinine ratio based on expert consensus is reducing proteinuria by a minimum of 50 percent in patients with a Uprot/Ucr between 0.2 and 1 mg/mg or a ratio less than 0.5 mg/mg for those with a baseline value >2mg/mg. (See 'Angiotensin blockade' above.) Angiotensin blockade therapy is considered in male patients in whom there is a high risk of endstage renal disease (ESRD) by 30 years of age (ie, those with large deletion, nonsense, or frameshift mutations of the COL4A5 gene) and who have microalbuminuria. (See "Assessment of urinary protein excretion and evaluation of isolated non-nephrotic proteinuria in adults", section on 'Issues with measuring urine albumin' and 'Phenotype-genotype correlation' above.) Supportive measures are initiated to prevent and treat complications of chronic kidney disease as they develop, which are discussed separately. (See "Overview of the management of chronic kidney disease in children".) Renal transplantation is the preferred option over dialysis for patients who develop ESRD. However, as noted above, there is a small, but not insignificant risk of developing anti-GBM antibody disease.

SUMMARY AND RECOMMENDATIONS Alport syndrome is a genetically heterogeneous disease that results from mutations in genes encoding the alpha-3, alpha-4, and alpha-5(IV) chains of type IV collagen. Xlinked, autosomal recessive, and autosomal dominant forms of the disease account for 80, 15, and 5 percent of cases, respectively. (See 'Genetics' above.) Clinical features and diagnosis Abnormalities of the alpha-3, alpha-4, or alpha-5(IV) chains of type IV collagen cause basement membrane impairment in the glomerulus, eye, and inner ear resulting in the clinical findings of Alport syndrome. The classical presentation of Alport syndrome is based upon clinical manifestations of affected males with X-linked disease. These features include glomerular disease that progresses to endstage renal disease (ESRD), ocular abnormalities (eg, anterior lenticonus), sensorineural hearing loss, and a positive family history of renal failure and hearing loss. Patients with autosomal recessive disease have a similar clinical presentation and course as those with X-linked disease, whereas patients with autosomal dominant disease generally have a slower deterioration of renal function. (See 'Clinical manifestations and course' above.) The initial renal manifestation of Alport syndrome is usually asymptomatic microscopic hematuria. Gross hematuria may also be a presenting finding, which may occur after an upper respiratory infection. The serum creatinine and blood pressure are normal in early childhood, but progressive renal insufficiency, hypertension, and increasing proteinuria develop with time. End-stage renal disease usually occurs in affected individuals between the ages of 16 and 35, but the course is more indolent in some families. (See 'Renal manifestations' above.) Women with X-linked Alport syndrome are heterozygous carriers of the gene mutation and have a range of clinical findings due to lyonization, in which only one X chromosome is active per cell. (See 'Carriers' above.) The diagnosis of Alport syndrome is usually suspected from the family history of renal failure and deafness. Confirmation of the diagnosis is made by either skin or renal biopsy. (See 'Diagnosis' above.)

Treatment There is no specific treatment to correct the underlying defect for Alport syndrome. In patients with Alport disease and overt proteinuria, angiotensin blockade therapy reduces the rate of protein excretion and appears to slow the progression of the disease. As a result, we recommend annual monitoring for proteinuria as soon as Alport syndrome is diagnosed, and treating any patient

with Alport disease and overt proteinuria with angiotensin blockade therapy using either an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) ( Grade 1B). It is reasonable to consider angiotensin blockade therapy in patients who have microalbuminuria, but have not yet developed overt proteinuria. (See 'Angiotensin blockade' above and "Treatment of hypertension in children and adolescents", section on 'ACE inhibitors/ARBs'.) We do not recommend cyclosporine therapy in patients with Alport syndrome (Grade 1C). Cyclosporine has not been shown to reduce the rate of renal disease progression and has significant side effects including cyclosporine renal toxicity. (See 'Cyclosporine' above.) Either dialysis or transplantation can be performed in patients with Alport syndrome who develop end-stage renal disease. The preferred modality of renal replacement therapy is renal transplantation. Recurrent disease does not occur in the transplant (since the donor glomerular basement membrane [GBM] is normal); however, approximately 3 percent of transplanted males develop de novo anti-GBM antibody disease. (See 'Renal transplantation' above and 'Anti-GBM antibody disease' above.